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Example: <br /> XIADE IN A 11011E KITCHEN <br /> Perndt#: 12345 <br /> f Issued in count. Count°name <br /> Chocolate Chip Cookies frith«Valuuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Auv here,CA 90NNX <br /> Ingredients: Emiched flour(Wheat flout.niacin,reduced iron.thiamine, <br /> nrolnorutrate.riboflavin olid folic acid),butter(milk,salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter,Wtle'fat(ruilk), walnuts,sugar.eggs. <br /> salt.artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,milia,sod-,walnuts <br /> i Net 11 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 /> i Pease Identify the water source.to be used in Cottage Food Facility(check one box) <br /> .54 Name of Public Water System or Community Services District: t— r7�ZCC, <br /> ❑ Private Water Supply**, Identify the source(well, spring, surface, <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 /> I <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.slovlpronramslPadeslfdbCottasleFood.aspx <br /> EHD 16-27 2/3117 4 CFO REGIPERMITTiNG FORM <br />