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SA NJ O A Q U I N Environmental Health Department <br /> w...00U N T Y . <br /> Example: <br /> MADE IN A HON11Z KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Coolies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lame <br /> Anywhere,CA 90`�`s"\ <br /> Ingredients: Emiched florrr(Wheat tlorrr,niacin,reduced iron.thiauiirte, <br /> mononitrate,riboflavin and folic acid),butter(hulk.salt),chocolate chips <br /> (sugar,chocolate liquor.cocoa butter,butterfat(milk), walnuts,sugar,eggs, <br /> salt.artificial vauiila extract_bakurg soda. <br /> Contains:Wheat,eggs,mill:,soy,walnuts <br /> Net Wt.3 oz.(81.5.049g) <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: <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:C4 It <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.gov/programs/Pages/fdbCoftageFood.aspx <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />