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SF NAO A QUI N Environmental Health Department <br /> --COUjly� Y-- <br /> Example: <br /> NIAM IN a HOME KITCHEN <br /> Penult p: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Salty Baker <br /> 123 Cottage Foal Lane <br /> Anywhere.CA 92\'s.^.C <br /> Ingredients: Eurichel flour(Mieat flow,amcm,reduced non,thiaruine, <br /> mononitrate,riboflavin and folic acid),.botter(unik,snit).chocolate chips. <br /> (sugar,chocolate liquor.cocoa buyer,bimerfat(milk), walnrus,sugar,eggs. <br /> sort,artificial vanilla e:stract,bakhog soda. <br /> Contains:Wheal.eggs,milk,toy,walnuts <br /> -Net Wt.3 az.(85.049g) <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 /> Yj 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) T <br /> [Name of Public Water System or Community Services District: la .�u, t)F l C-aC� <br /> ❑ Private Water Supply**, Identify the source(well,spring, surface, etc.): � <br /> Private Water Supp/y: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: <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(CDPH) <br /> food processor course. <br /> For more information see CDPH website www.edph.ca.aovlproomms/PauesffdbCottaneFood.asi) <br /> IPaaesBdbCottaneFood.asox <br /> 4 of <br />