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SANAAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit #: 12345 <br />Issued to eoustr. County mane <br />Chocolate Chip Coolies With Walnuts <br />Sally Baker <br />123 Cottage Food lace <br />Anywhere, CA 90.VLX <br />Ingredients: Enriched flay (ALeat tour. uiacm, reduced iron, thiamine, <br />mononitrate, nboflmvin and folic acid), butter (milk-. salt), chocolate chips <br />(sugar. chocolate liquor, cocoa butter. burterfat (milk), wabmts. sugar. eggs. <br />salt, artificial vanilla extract. bakine soda. <br />Contains: RLeac eggs, milk, soy, walnuts <br />Net Al L 3 oL (85.049g) <br />Note: For the 'Issued in County'- Identity 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 ❑ 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 />[tj Name of Public Water System or Community Services District: %V4 b Y Mot r\�9— r✓C,� <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 & <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 nater 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.odph.c-tqaviPm-grams/PagestfdbCattageFood.aspx <br />4 of <br />EHD 16-276119117 CFO REGrPERMrrrING FORM <br />