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SA K Q A Q U IN Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> NIADE IN A HOME KITCHEN <br /> Permit R: 13345 <br /> Issued to count•: Countymune <br /> Choaolnte Chip Cookies%Vith Wnluuts <br /> Snlly Bakrr <br /> 123 Coltoac Food Lure <br /> Antivhee.CA 90%'R\ <br /> Ingredlvpw Enriched Boor(Nbent Bon",oineiu,redoced itoo,titiotuine, <br /> nrououitmtc,ribotInviu mud folic ncid),butter(milk.Wit,chocolme chips <br /> (sugmt choeolnte liquor,cocoa boner,bullotat(milk), %\alum sugar,eggs, <br /> salt,mtilicinl emdlla cxlmm baking soda. <br /> Contains:Wheal,eggs,milk,soy,oohmts <br /> Net\F't.3 ox.(85.0.19g) <br /> Note..For the'Issued in County"-Identify the jurisdiction(cilylcounty)where you are obtaining approval. <br /> S. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> ZZIPUblic 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 /> -E Name of Public Water System or Community Services District: <br /> ❑ Private Water Supply", Identify the source(well, spring, surface,etc.): <br /> PrNate 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 information 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: �?S <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.odnh.oa,aoviprociranis/PanesndbCottatieFood.aspx <br /> —_—_—._...____..._—__—__.__. 4,of.5... <br /> EHD 16-276129117 CFO REGlPERMITTING FORM <br />