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SA N J o n Q I I I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> \LLDE IN A HOME KITCHEN <br /> Permit r: 1234,5 <br /> Issued in counri: CountY name <br /> Chocolate Chip Cooldes With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90XXX <br /> Ingredients: Enriched flour(Wheat flour,niacin.reduced iron.thiamine, <br /> mononitrate,riboflavin and folic acid).butter(mill-,salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(urilk), walnuts.sugar.eggs. <br /> salt,artificial vanilla extract.baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> .Net N11 3 oz.(3,5.0.19-1) <br /> Note:For the"Issued in County"-Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Ple se check what type of treatment is used to dispose of waste <br /> ublic 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 /> ;KZdentify the water source to be used in Cottage Food Facility(check one box <br /> e of Public Water System or Community Services District: <br /> ❑ Private Water Supply**, Identify the source (well, spring, surface, <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: 4He <br /> Within 3 months of being approved to operate by the Environmental Health Department, pleasoof <br /> of completion of the California Food ndler urse in lieu o`Ve Califo la e ment ublic <br /> (CDPH) foodprocessor course. 0(V Q 1 xn V0 ke— <br /> p <br /> For more information see CDPH website www.cdph.ca.gov/programs/Pages/fdbCottageFood.aspx <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />