Laserfiche WebLink
SANyJ o A Q U I N Environmental Health Depatttnent <br /> COUNTY <br /> Example: <br /> MADE IN A HONJEc 1UTCHIEN <br /> Permit H; I234i <br /> Issued In county: County name <br /> Chocolate Chip Cookies I[rith Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90.3001 <br /> Ingredients: Enriched flour(Wheat flour,niacin,reduced iron,(hiamine, <br /> ruononitrate,riboflavin and folic acid),butter(milk,salt),chocolate eltips <br /> (sugar,chocolate liquor,cocon butter,butterfat(milk), Nvalnuts,sugar,eggs, <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:Wheat,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 /> E� Public Sewer Service ❑ Private Septic System <br /> r <br /> In the event of septic system failure or plumbing problem,you are required to notify San Joaquin County Environmentaf Health Department g <br /> immediately. <br /> 7. Water Source: F <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: City of Manteca Water Division <br /> ❑ Private Water Supply**, Identify the source (well, spring, surface,.etc.): <br /> Private Water Supply: Initial Water Quality Results j <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 Systerns after initial testing) ; <br /> s <br /> ❑ Bacteriological Test(quarterly*): <br /> ❑ Nitrate Test(yearly*): <br /> ❑ Nitrite Test(every 3 years*): <br /> i <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 /> l <br /> For more information see CDPH website www.edph.ca.gov/programs/Pages/fdbCottageFood.aspx <br /> 4 of 5 <br /> EHD 16-27 6/29117 CFO REG/PERMITTING FORM 3 <br /> l <br /> 6k <br /> i <br />