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;2 <br /> !, H J l-) y ( � I N Environmental N2alih Department <br /> L()!.j I� l <br /> i <br /> Example: <br /> \1ADL INA ll0\I1. I.l I( Ill.'\ <br /> Pet mil=: 12345 <br /> I„ucd w connll: c uuun n.unc <br /> Chiu ll•1ta(bill(vokie,%%fill U allilit, <br /> t,,Ill [sdl♦'1 <br /> I�i(,Nt.lt.'C I-14N)I.Illi <br /> .filly% brl e.(A`rIC.C\ <br /> In_redienh: Fns lched 11,4111\%11ca11lntu ni7im Irdr11ed it no 1111.111111 be <br /> nl.ulxuu.rr.labollawul and ralic.Lull Inntel Uudl..-.Ili d"X0.1a cliff', <br /> tSueat.cllckedate 114111ol.cocoa l+ugel hall.l1.1111ndk1. na6uu. ,n^.n.cr <br /> 'Al alplicl.d lauilla c\t1m1 bAII12•oda <br /> 1 Init.liuc:\1 hr.11.1^e.mill:.lm.11abIn1% <br /> X11�t 1.=u/•I�i,rl�')�► <br /> MMIC For Me'Issued rn County'-Identity litelurtsdictiott(ctfy/county)whir you ate obtaining approval <br /> 6. Disposal of Waste: <br /> Please check what type of treatfnent Is used to dispose of waste <br /> Public Sewer Service ❑ Private Septic Systern <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 t'✓ater source to be used in Cottage Food Facility(check one box) <br /> Name of Public Water System or Community Services District CALF Feoer-IM h/ItTM <br /> _ _ I <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 Crater 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 requtled if food is prepared from a home with a pttvaln water supply—check wills local lutisdidion <br /> 8. Food Processor Course: Initial if you agree to abide by the following: 02�slr� <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 /> I or more information see CDI'li website www.cdph.ca.clov/programs/Pages/fdbColtageFoo(l.aspx <br /> a of 5 <br /> EHU 10.27 6129117 crO REG'PERM11 TING WRM <br />