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SAN ­JOAQUIN <br />— <br />COUNTY - <br />Environmental Health Department <br />Example: <br />MADE INA HOME KITCHEN' <br />Permit q: 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere. CA 90.CR.0 <br />Ingredlents: Enriched flour (Mient flour. niacin. reduced iron. thiamine. <br />mononitrate. riboflavin and folic acid). butter (milk. salt), chocolate chips <br />(swear. chocolate liquor. cocoa butter'. butterfat (nalk), walnuts. sugar. eggs. <br />salt. artificial vanilla extract, baking soda. <br />Contains: R'hent, eggs, milk, soy. walnuts <br />Net 111. 3 oz. (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 />'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 />Name of Public Water System or Community Services District: L ndkn CQtivt+� <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 maybe 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: �V <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.ca.aov/procirams/PagestfdbCottaaeFood.asox <br />4 of 5 <br />EHD 16-276/29/17 CFO REG/PERMITTING FORM <br />