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Ir <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit 4: 12345 <br /> Issued in county: Countyname <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90)M <br /> Ingredients: Enriched flour(Mieat flour,niacin,reduced iron,thiamine, <br /> incriminate,riboflavin and folic acid),butter(milk,salt),chocolate chips <br /> (sugar,chocolate liquor,cocoa Butter,butterfat(milk), walnuts,sugar,eggs, <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:wheat,eggs,milk,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 <br /> Department immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> Flame of Public Water System or Community Services District: &---CAA 6-AM141S� <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 /> ❑ Nitrate Test(every 3 years*): <br /> -Additional infonnation may be required if food is prepared from a home with a private water supply-check with local jurisdiction. <br /> `l A5 boad Yna)'Ve.- <br /> 8. Food Processor Course: Initial if you agree to abide by the following: <br /> Within 3 months of being approved to operate by the Environmental Health Department, please <br /> provide proof of completion of the required California Department of Public Health (CDPH)food <br /> processor course. <br /> For more information see CDPH website www.cdph.ca.gov/programs/Pages/fdbCottageFood.aspx <br /> EHD 16-2712/27/2012 3 CFO REG/PERMITTING FORM <br />