Laserfiche WebLink
SAN10 A Q U I N Environmental Health Department <br /> COUNTY <br /> Example: <br /> MADE I\a HOME KITCI N <br /> Permit#: 12315 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 1';Cottage Food Lane <br /> .Jmvhere.C_-190\XX <br /> Ingredients: Emiclred florin('Alieat flour.niacin,reduced iron.tltian»ne. <br /> nrononivate.riboflavin and folic acid).butter(milk,salt).chocolate clops <br /> (shear.chocolate liquor,cocoa butter,butterfat(milk). walnuts.suaar.ee2,. <br /> salt,artificial vanilla extract.baking soda. <br /> Contains:AN-heal.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 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: it .�� 4- L� <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.qov/programs/Pages/fdbCoftageFood.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />