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SAN JO'AQUIN <br />)UNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HQUE KITCHEN <br />Permit N: 12345 <br />luued in county: County name <br />Chocolate Chip Cookies with walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere. CA 90\..'1.\ <br />Ingredients: Enriched flour (jlgicat flour. niacin. reduced iron. tluantme. <br />monoui(rte, riboflavin and folic acid). batter (hulk. salt). chocolate chips <br />(sugar. chocolate liquor, cocoa butter, butterfat (milk). walnuts. sugar, eggs. <br />salt, artificial vanilla extract, baking soda. <br />Contains: Wheat, eggs, Milk, soy, walnuts <br />Net NY. 3 oz. (85.0498) <br />Note: For the "Issued in County" - Identify the junsdiction (citylcounty) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />I?L 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: G ' 11 or Mm <br />flu <br />❑ Private Water Supply", Identify the source (well, spring, surface, etc.): 1 <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 & <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 infonnadon may be required if food is prepared from a home with a private water supply —check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: JMJ j <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 www.cdoh.ra.aov/oroaramslPaaeslfdbCottaneFood.asox <br />4 of 5 <br />EHD 16-27 6129117 CFO REGIPERMnTING FORM <br />