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SA N,J O A Q U IN Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit k: 12345 <br /> Issued In count': County name <br /> t <br /> Chocolate Chip Cookies With Walnnts <br /> Salle Bakes <br /> 123 Con,12c Food Lane <br /> Antm7tere,CA 901,11' <br /> ingredients: Enriched Ilotn(119reat ttont.niacin.reduced iron.tluanune. <br /> mm�onihatg,riWBarin and folic acid),buttes(nu1k.whit chocolate chips <br /> (sugar,chocolate liquor.cocoa boner.buuetfat(hulk), svalnuts.sosar,eggs. <br /> salt,artificial sanilla extract,baking soda. <br /> Contains:Wheal.eggs,milk sop,sealants <br /> Net%V1.3 o7.(95.049g) <br /> Note:For the'Issued in County"-Identify the juh diction(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 Depa tsrrem <br /> immediately. <br /> 7. Water Source: <br /> Pease Identify the water source to be used in Cottage Food Facility(check one box) <br /> VName of Public Water System or Community Services District: %ck*il_ AAWfur�` <br /> ❑ Private Water Supply", Identify the source(well,spring,surface,etc.): V <br /> Private Water Supply.Initial Water Quality Results I <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 vin local junsdichon,nn,,' )) <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 infonnanon we CDPH website www.cdph.c&qm/prmramsiPaaesMdbCottageFood.asox <br /> 4 of 5 <br /> EHD 16-27"117 CFO REGIPERMnTING FORM <br />