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SANM Q U I N Environmental Health Department <br /> C©UN7Y-- <br /> Example: <br /> \LADE IN A HOME KITCHEN <br /> Permll M: 12345 <br /> issued in county-County name <br /> Cluwtilate Clup Csx kie,NPIIII 1Ca1111 it, <br /> S�illr Dnker <br /> 11",fonnFe Fnxl Lmc <br /> :1ns\sltere.CA MWCX <br /> Ingredlertm Etmchol Oxu Olicat Ilan.niacin.minced trim.duaudue. <br /> numorunate, <br /> ntainaoi turd folie acid).btmer tunik.,alt L chocolate chips <br /> Lugar,chocolate liquor.crena lnmer.bwtetfit(ntlk).tcahmt,.sugar.egg,. <br /> �1It.anrGcial cauilla C\nmt baGne,xh <br /> C'ontalnu%%beat,eggs,milk,soy,Watnuts <br /> Net WL 3 oz(85.0499) <br /> Note:Forlhe"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 X 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 <br /> Q Private Water Supply",Identify the source(well,spring,surface,etc.): wpli-I <br /> Private We ter 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 provlde 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.ednh.ca.gov/progrramsfPagestfdbCattageFood.asuz <br /> 4of5 <br /> EHD 16-27 6/29117 CFO REGr.ERMrrTNG FORM <br />