Laserfiche WebLink
FIANJOAQUIN Environmental Health Department <br /> COUNTY— <br /> Example: <br /> NIADE IN A HON'fE KITCHEN ill P <br /> Perwit li: 12345 <br /> Issuedlncoun0% Countynnme <br /> ClI mime Chip Cookies With 1Wahuns <br /> sally Baker <br /> 123 Connge Food Lune <br /> Ainis$tiz.CA 90]SXX <br /> Ingredients: Enriched Oau(Wheat flour,nincbi.reduced iron,thiamine, <br /> niouown-me.ribollmdn mid folic acid).butter(inilL snlQ,chocolate chips <br /> (sugar.cliacelme liquor.cocon butter.lnmerfat(nut}:). tmhmts.sugnr,eggs. <br /> salt.artificial stuulla extinct,baking soda. <br /> Contains:Wheat.eggs,mlll:,soy.walnuts <br /> Net R9.3 o7.B5.049g) <br /> ofW For the'Issued in County'-Identify the Jurisdiction(city/countyl whom you are obtaining approval <br /> 6: Disposal of Waste: <br /> u <br /> leeaasa check what type of treatment is used to dispose of waste <br /> iii Public Sewer Service ❑ Private Septic System <br /> In the event of septic system failure or plumbing problem,you ata required to notify San Joaquin County Environmental Hearth Department <br /> mmedlatey. <br /> 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:L w 1 <br /> C] Private Water Supply**, Identify the source(well,spring, surface,etc.): <br /> Private Water Supply:Initial Wafer 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 it 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: C°AI(1 <br /> I <br /> Within 3 months of being approved to operate by the Environmental Health Department, please provide proof. <br /> bf completion of the California Food Handler course in lieu of the Califomia Department of Public Health <br /> (CDPH)food processor course. <br /> I <br /> 1,or more information see CDPH website www.edph.ca.gov/pmgmms/Pages/fdbCottageFood.asl3 <br /> 4 of <br /> EHD 16?7 e129/17 CFO REGIPERMrrnNG FORM <br />