Laserfiche WebLink
1 f-4 1 i M o u ll IN Envirci if3 entai tieaitn tiecarn-Tent <br /> `,-.i — V <br /> Example: <br /> NIADF h1 A 110'%[E KITCHEN <br /> 1'crmit=: 12345 <br /> 1%%ued in county: County name <br /> Chocolate Chip Cookie,With Wahnn, <br /> Sally Baker <br /> 123,Conaue I o,u1 lame <br /> n%%hen•.CA 9(11 .\ <br /> Ingredients: Fnriched flour i 1\licat flour,niacin.leduct(l iron.ilunnime. <br /> Inom tivale.ribollaciu and folic acid).bwlei unilk.,alo.chucoli le chip, <br /> ,usn.clx,colaie li(iuor.cocoa butter.butterfat Caulk). aaluus.atgar.eggs. <br /> .alt.aniticial vanilla extra,ct.bakine soda. <br /> Contains:Wheat.eggs,mill:.sov.walnut% <br /> Net R't.3 oz.(35.049x) <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 /> 9 Name of Public Water System or Community Services District: L.V11"dY ��'/•. e�tS� <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: , 99 <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.aoviprograms/Panes/fdbCottaneFood.aspx <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />