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Environmental Health Department <br /> SANIOAQUIN <br /> Example: <br /> :...... ....._............. <br /> ...:\7ADE-I1�.A:IdOn7L:KTTCliE1i;; ;;i;ii i ':;ii;..":::• <br /> .............. <br /> illtf' It <br /> ;:::::p:E.-;;.,:..,,..__.,_......,_ <br /> ^� Inued In counh Gpunn name• 't=i:::�"°•"��"°"'""•"0' : <br /> ii:^iE�'i::.••'•'••:::i,^:::::::•_•,�iiit::'S�iiiiE�i"ioaE?if".eii�riieii�i:F'r::i° :rr7::)::................... <br /> . ,r�i:i"3:-;: ... -.x::• ti::in.. •:Jai::!:a:.:.............i?i5ii?a ni <br /> iie e:.:.:,:u::,::. r.... ..... <br /> irEI` E °::... ::q:E^.r ,:p:q::_:Ev.:::....:.:. <br /> ............. <br /> it im. <br /> : Chocolate Chr Cookies With,N`aliwtB"Es:�.:i::::::;_•:,:_.,,. <br /> o ...ii:i"a <br /> ,:4.:;:I1:o �.:iiii°'3'::°`��i;1�:.:Eu:i��......_:ii5ii;ii{iii5�ii:i.:^:•,:�!ii:a:. <br /> iii;:iiiiie:iii;i$iriciiiii!iidiiiiiiiii?1•i°'i°^ii[ia"":ii`:e Siiriii'c°5iiii�iiE3:i3ii�iiiiiiifi�i3i��'iEiiE! <br /> ......... .. <br /> i;ingredlenis Eonched Hrnv(Wlreat Hmu_gtacm tzdticed uvn Huw}une!,i;;;;�i; <br /> [monmuimte.nbollp}tin"and'toticact�abuHer(nuIA��11t1 drocolate c6tpt ; - <br /> ;(sugrr chocolate hcptor cocoa boner.butterfat(twli.) svriWuts sitmv eggs , 3 <br /> sob;arhficinl;i•amlla extrtibf bal.mg sodatt t:ia[;::::::�•...a <br /> N.................. ......... ..... <br /> ... 3fiii-,:...;�niE�iiii::::v:: EE: 'F.;�'ii.;,:.:::r,?:n:::.::'.[{.;,.....:r:r..,..,.•::i::,":i <br /> "Coo :R'heat;a 5rNi11.;`so}':}saltlbtS:-_,;;:"':"I'`' "'i`3aio•" ,iiai :; iil <br /> :::.. _.. ..............................::_::. ....:._,.:.,.: 1.r:�2:iirlki:cS.iSeiki! <br /> .............. .. ....�q........ ...:::c?E::?:^iii <br /> ui"r.:E!2i� : ^:' °ii iiiihel d19::9`m.'• 5:1119 d:i:ilii;:ii"ii 'IE:i:�ii3ieziiiii'iiiii'ii <br /> :....... ..............iFi ; ':°:...........::..It'-✓:::.r... <br /> .............rwa�a:::: <br /> Note:For the'Issued in County"-Identify the jurisdiction(city%county)where you are obtaining approval.' <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> Public Sewer Service ❑ Private Septic System <br /> In the event of septic system failure or plumbing problem,you are required to notify San Joaquin County Environmental Health Department <br /> immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) ' <br /> [Name of Public Water System or Community Services District: kfp�, <br /> ❑ Private Water Supply", Identify the source'(well, spring, surface, etc.): <br /> private Water Supply:Initial Water Quality Results <br /> Check boxes below if initial water testing has been completed. ° <br /> Al testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab,date& <br /> results in space provided next to type of test. <br /> '(Testing frequency for transient Non-Community Water Systems after initial testing) . <br /> ❑ Bacteriological Test(quarterly'.): <br /> ❑ Nitrate Test(yearly'): <br /> ❑ Nitrite Test (every 3 years'): <br /> -Additional information may be required if food is prepared from a home with a private water supply-check vnth local jurisdiction. <br /> I <br /> 8. Food Processor Course: Initial if you agree to abide by the following: <br /> Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br /> of completion of the California Food Handler course in lieu of the California Department of Public Health <br /> (CDPH)food processor course. <br /> For more information see CDPH website�.cdoh.caaovloroaram�aae�fdbC�aeFood.asoxcdoh.ca.aovloroaram�aae�fdbC�aeFood.asox <br /> 4 or <br /> EHD 16-276129117 CFO REGIPERMF TING FORM <br />