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SANJ O A Q U I N Environmental Health Department <br /> Example: <br /> Fn�,ffilmv.l <br /> IN A HOME KITCHEN' <br /> Permll R: 1I $ <br /> to nounn: Cvuvty mme <br /> m CWP Ctxkl w'nh\\'Almy+ <br /> c Ih avkn <br /> _3 CM.'F.v,f Um ' <br /> moireC:1 Wvvc'1\\Lnl t1Mnivuchirtliunl mni Jvmwir. <br /> , hc.cid).butt mark.aIt)d.01h1e vhlln <br /> twc r clxwl.r Igmx.cxm Ixrner.Nowt.,(uulkl.Ilalnrns.myar.a rr' <br /> .h.mnficul Imrilh coal.tmklll¢'x' <br /> Cavrvlm:MLaL M,mal.+a, walnen <br /> %M Wt.3 oz(115.11499) <br /> No le:Far the-Iwwd in County--hAmdry the junsdwhon(dfyAwuMy)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 .4 Private Septic System <br /> In the event of septic system failure or pWmbing problem,you are required M notify San Joaquin County Environmental health Department <br /> immediately.—Vqp <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 /> Private Water Supply",Identify the source(well,spring,surface,etc.): (ji Lf L, <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 /> '(resting frequency for transient Non-Community Water Systems after initial testing) <br /> 94Bacteriological Test(quarterly'): <br /> 10 Nitrate Test(yeady'): <br /> ZNitrite Test(every 3 years'): <br /> "Adel ional information may be required a food's prepared from a home with a private water supply—d with lora)j,,nsQ¢tion. <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 Cal)fomia Food Handler course in lieu of the California Department of Public Health <br /> (CDPH)food processor course. <br /> For more information we CDPH website www.edgh.ca.govtprwmms/PaqestfdbCottageFo d.a yx <br /> FJf01f>27 SIM 17 CFO REGRERMIRNG FORM <br />