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Example: <br /> MADE IN A HO>\IE KITCHEN' <br /> Permit#: 12345, <br /> Issued in countY: Comity name <br /> Chocolate Chip Cookies With Walnuts <br /> Sall•Baker <br /> 123 Cottage Food Lane <br /> atyxyhere.CA 90LV1 <br /> Ingredients: Enriched flotu Mlteat tlom.niacni.reduced iron,thiatrnue. <br /> nronouinate,tibotlayin and folic acid).butter(milk-,salt).chocolate chips <br /> (suear.chocolate liquor,cocoa butter.butterfat lutilk). walnuts.sugar.eggs. <br /> .alt,artificial yauilla extract,baking soda. <br /> Contains:Wheat,eggs,mill:,soy.Walnuts <br /> Net«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 <br /> Department immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> rV <br /> Name of Public Water System or Community Services District: C�ry D l Ma te-C ct—, <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 <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.gov/programsiPages/fdbCottageFood.aspx <br /> EHD 16-27 2/3/17 4 CFO REG/PERMITTING FORM <br /> 5 <br />