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SA NsJ 0 AQ U IN Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit a: 13345 <br /> Issued In munn,. County name <br /> Chocolate Chip Cookies\\5th Walnuts <br /> stilly Bnkw <br /> 133 Cottage Food Une <br /> Amavitrm.CA 90.=X <br /> Ingredients: Ewicbed Bart(\\7sent ltonr.niacin.mhiced irmt thimnine. <br /> watmlitmle,riboflavin and folic arid).butter(milk,salt).chocolate chips <br /> (sugar,clancolare liquor,cacao miner,inner fat(milk). walnuts sugar.egos. <br /> Wt.artificial vanilla extract,diking 106, <br /> Contains:Wheat,eggs milk soy.walnuts <br /> Net\\'L 3 at(85.0499) <br /> Note:For the'Issued in County-.Identify the)unsficdon(crtykounty)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> PPublic 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 /> Name of Public Water System or Community Services District: I A l roe <br /> ❑ Private Water Supply",Ida"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 8 <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 serer 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 Cardomia 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.edoh.ee.nov/proarems/PaaesRdbCatteaeFoad.aspx <br /> 4 ors <br /> EMD 1627 629/17 CFO REG/RERMIITING FORM <br />