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Example: <br /> MADE In a HOME KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Auywhem CA 90.'VCX <br /> Ingredients: Enriched floor(%'neat flour.nniaciu,reduced iron.thiamine. <br /> m000narate.riboflavin and folic acid).butter h nilk,salt),chocolate clips <br /> (sugar,chocolate liquor,cocoa butter.butterfat(nalk), walnuts,sugar.eggs, <br /> salt.artificial vanilla esnact.baking soda. <br /> Contains:Wheat,eggs,mill:,soy,walnuts <br /> Set Wt.3 oz.(85.0498) <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 /> 9 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 /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> 9 Name of Public Water System or Community Services District: CI+1�, _( . t 1 <br /> CLn+C <br /> F-1PrivateWater Supply**, Identify the source (well, spring, surface, etc.): yt N I <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 <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 /> For more information see CDPH website www.cdph.ca.covlproarams/PaaeslfdbCottaneFood.aspx <br /> EHD 16-27 6/29/2015 4 CFO REG/PERMITTING FORM <br />