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SAN JOAUUIN <br />OUNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HO\E KITCHEN <br />permit#: 12345 <br />Issued In county-. County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Conage Food Lane <br />Amxvhere. CA 90_'00T <br />Ingredients: Enriched Flow (t1Lem fbyr`iaachr reduced iron. domains. <br />munonitmte, ribollavin and folic acid). buaerJutilk. salt), chocolate chips <br />(sugar. chocolate liquor. cocoa bower, tottafat (nua). nahtms. must. eggs. <br />sah. artificial vanilhi extinct. banns soda. <br />Contains: 1% Leat, eggs, mill:, soy, walnuts <br />Net Wt.3 oz. (85.019g) <br />Note: For the Issued in Counly'- Identify the junsdiceon (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 failum 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 />N Name of Public Water System or Community Services District: San Joaquin, Tracy <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 Slate Certified Laboratory. Either attach lab results or provide name of lab, date 8 <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 Ifood 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: MA <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_.cdph.ca.gov/pmgramsiPaueshdbCottaueFoodaspx <br />4 of <br />EHD 16-27 6rte/17 CFO REG/PERMITTING FORM <br />