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w <br /> i .. <br /> Example: <br /> MADE]IN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Coolies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90 X—K <br /> Ingredients: Enriched flom(Wheat flour,niacin,reduced iron,thiamine, . <br /> mononitrate,riboflavin and folic acid),butter(quill:,salt),chocolate chips <br /> (sugar,chocolate liquor;cocoa butter,butterfat(ruin;), walnuts,sugar,eggs, <br /> i salt.artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts. <br /> Net Wt.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 <br /> Department immediately. <br /> i 7. Water Source: <br /> -P �e Identify the water source to be used in Cottage Food Facility(check one box) <br /> (LEiName of Public Water System or Community Services District: G <br /> i ❑ Private Water SuppI * 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 />! <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. f=ood 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 <br /> provide proof of completion of the California Food Handler course in lieu of the California Department <br /> of Public Health (CDPH) food processor course. <br /> E For more information see CDPH website www.edi2h.ca.g43v/programs/Pages/fdbCottageFood.aspx <br /> I <br /> EHE 16-27 8112/16 4 CFO REGIPERMITTING FORM <br />