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SAN JOAQUIN <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN' <br />Permit M: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baket <br />123 Cottage Food Lave <br />Auvvvhere. CA 90.=X <br />Ingredients: Emiched flour Mlicat flour. maciu. reduced iron. du miue. <br />momonitmte. riboflavin and folic acid). bunter UmIL salt). chocolate chips <br />(sugar. chocolate liquor. cocoa boner. butterfat (inilk). walnuts. snear. eegs. <br />salt. artificial vanilla extract. baking sods. <br />Contains: Wheat, eggs, ndik, $o)', walnuts <br />Net Wt. 3 oz (&4.0499) <br />Nota- 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 <br />❑ 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: MO V NTAtt4 HOkS% CoMM UNi V <br />St=RVICEi DISTRICT <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 />All testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab, date E <br />results in space provided next to type of test. <br />'Cresting 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 with 1=1 jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: __ S <br />Within 3 months of being approved to operate by the Environmental Health Dopartment, please provide proof <br />of completion of the California Food Handicr course in lieu of the California Department of Public Health <br />(CDPI1) food processor course. <br />For more information see COPH wetrsite www,c_dph_ra.gdvlprQgramslimagesltdbCgt arood.asox <br />4 of <br />EHD 16-27 612917 CFO REGIPERMITTING FORM <br />