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SA N siJ O A O U I N Environmental Health Department <br /> COUNTY <br /> Example:Example: <br /> NtADE IN A HOME KITCHEN <br /> Permit N: 12345 <br /> Issued in county: County name <br /> Chocolate Clip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Any%vhere.CA 90\M <br /> Ingredients: Enriched}lour(Wheat flour,niacin,reduced irou,thiamine. <br /> mononitrate,tiboflmi and folic arid),boner(milk,salt),chocolate clips <br /> (sugar,chocolate liquor,cocoa butter.butterfat(milk), ealmms,sugar,eg_es, <br /> salt,artificial vanilla extract,baking soda. <br /> Contains.Wheal,eggs,milk,soy,walnuts <br /> Net NV.3 oz(85.0498) <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 /> 2Name of Public Water System or Community Services District: N46W9�YIf�S <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 N 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 /> Within 3 months of being approved to operate by the Environmental Health Department, please vide 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.osloh.ca.aovloroaramslPaaeslfdbCotfaaeFow.osox <br /> 4 of <br /> EHD 16-276/29117 CFO REGMERMI'TTING FORM <br />