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SAN IOAQUIN <br />—COUNTY <br />Environmental Health Department <br />Example: <br />INLADE UN A HOTIE KITCHEN <br />Permit 4: 12345 <br />Issued in county: County name <br />Chocolate Chip Cooldes With Walnuts <br />Sally Baker <br />123 Conage Food Laue <br />Anwhere, CA 901C%_X <br />Ingredients: Enriched flour (Wheat flour, niacin. reduced iron, diamine, <br />tnonouitrate. riboflavut and folic acid), butter (uiilk salt), chocolate chips <br />(sugar, chocolate liquor, cocoa buner. butterfat (milk), walnuts. sugar, eggs, <br />salt, artificial vanilla extract, baking soda. <br />Contains: Wheat, eggs, mill:, 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 />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 />EC /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: , G <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.r-a.gov/programs/Pages/fdbCottageFood.aspx <br />4 of 5 <br />EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />