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SA NA O A Q U IN Environmental Health Department <br /> COUNTY— <br /> Example: <br /> MADE INA HOME KITCHEN' <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Clip Cookies With A Minas <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90.VLX <br /> Ingredients: Enriched flour(Wheat flour,tiacin,reduced iron,thiamine. <br /> mononitrate,riboflavin and folic acid).butter(milk,salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk), walnuts,sugar.eggs. <br /> salt.artificial vanilla exit act.baking:soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net R'1.3 oz.(55,049g) <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�ofr�waste <br /> ❑ Public Sewer Service �wrivate 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 /> Private Water Supply", Identify the source (well,spring, surface, etc.): -PFL Jm-E, (,JF- <br /> A\-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'): o_ 1 I <br /> (Nitrate Test(yearly'): r/ <br /> IQ- � - 1 <br /> ANitrite Test(every 3 years*): �n_ I _ <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 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.edph.ca.gov/g)rograms/Pages/fdbCottageFood.as x <br /> 4 of <br /> EHD 16-27 6/29117 CFO REG/PERMITTING FORM <br />