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Example: BIG CAKE BAKER Stockton CA 95209 Perm it#012345 Issued in: San Joaquin County Chocolate Chip Cookies with Walnuts Ingredients Enri&ed flour(wheatflour,niadr,reduced iror,thiamine,mononitrate,riboflavin and fol¢acid),butter Irrilk,salol,&ocolatechips(sugar,chocolate liquor,camabutter,butterfat ImiW,walnut;agar,eggs,salt,artifidalvanita e¢ract,belong soda NoteFor the'Issu, Contains: Wheat, milk,eggs, Soy, walnuts 6. Disposal of Waste: Made in a home kitchen Please check what type r Net Wt. 3 oz.(85.058) ,,K Public Sewer Service In the event of septic system failure or plumbing problem,you are required to notify San Joaquin County Environmental Health Department immediately. 7. Water Source: Pease Identity the water source to be used in Cottage Food Facility(check one box) Name of Public Water System or Community Services District: pAu f'-ln,w I CA ❑Private Water Supply", Identify the source(well,spring,surface,etc.): 7�� Private Water Supply.Initial Water Quality Results Check boxes below if initial water testing has been completed. All testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab,date& results in space provided next to type of test. `(Testing frequency for transient Non-Community Water Systems after initial testing) ❑Bacteriological Test(quarterly*): ❑Nitrate Test(yearly*): ❑Nitrite Test(every 3 years`): —Additional information may be required if food is prepared from a home with a private water supply—check with local jurisdiction. 8. Food Processor Course: Initial if you agree to abide by the following:(" Within 3 months of being approved to operate by the Environmental Health Department,please provide proof of completion of the California Food Handler course in lieu of the California Department of Public Health(CDPH)food processor course. For more information see CDPH website www.cdph.ca.gov/programs/PacteslfdbCottageFood.aspx EHD 16-27 6/29/2023 4 CFO REG/PERMITTING FORM