Laserfiche WebLink
SAN10 A Q U I N Environmental Health Department <br /> -- C OU NTY <br /> Example: <br /> MARL INA HOME KI IVIR:N <br /> Permit=: 12345 <br /> Issued in Coumh: Counh name <br /> Chocolate Chip Cookies With wahrrtts <br /> Silly Baker <br /> 1'_;Cottage Food Lane <br /> .almshere.CA 90LCC <br /> Ingredients: Enriched thnu(Wheat flour.niacin.reduced iron.thiamine. <br /> monouinnte.ribotlav in and tiilic:mill.butter(milk ,alt),chocolate chips <br /> (Ungar.chocolate liquor.COCoa butter.butterfat i 11111k). Nvalnuts.S1181r,eggs. <br /> ,alt.artificial vanilla exuact.bakins soda. <br /> Contains:Wheat,eggs,milk,soy.iialnuts <br /> Net N1 t.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 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.): <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 /> *(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 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.cdph.ca.gov/procirams/Pages/fdbCottageFood.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />