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SANAA Q U I N Environmental Health Department <br /> COUNTY— <br /> Example: <br /> 'MADE IN A HOME IQTCHEN <br /> Permit p: 12345 <br /> Issued In county: Count name <br /> Chocolate Chip Coolies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane - <br /> Anllvhere.CA 90\'la <br /> Ingredients: Enriched(lour(Wheat flour.nincin,reduced im»,thiamine, <br /> monmtihate,riboflavin and folic acid),butter(milk,salt),chocolate clips <br /> (sugar.chocolate liquor.cocoa hurter.butterfat(milk), %mlnuts,sugar,eggs. <br /> salt,artificial smnilla extract,baking soda. <br /> Contalus:Wheat,eggs,mill:,soy,"%"[nuts <br /> Ret Wt.3 oz(85.049g) <br /> Note,,For the'Issued in County'-Identify the jurisdiction(city/courtly)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 Heath Department <br /> immediately. <br /> 7. Water Source: <br /> Pease Identity the water source to be used in Cottage Food Facility(check one box) <br /> P Name of Public Water System or Community Services District: eTI2 <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(quartedy*): <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: <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,edph.ca.govioroprarns/PaaesifdbCottaaeFood.aspx <br /> 4of5 <br /> EHD 1627 629/17 CFO REGIPERMITTING FORM <br />