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SA N X10 A Q U I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> NIADE IN A HOAIE KITCHEN <br /> Permit H: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Collage Food Lane <br /> Anymdtere.CA 90=X <br /> Ingredients: Enriched flour(When flan.macht,reduced iron,tlunnrine. <br /> mlononimite,riboflavin and folic acid).Miner(milk,salt).chocolate chips <br /> (sugar,chocolate liquor.cocoa butter,Mnterfid(milk), onhuds,sugar,eggs. <br /> mit.artificial tauilla extract,baking soda. <br /> Contains:Wheat,eggs,milk soy,walnuts <br /> Net R9.3 oz(85.0498) <br /> Note:For the Issued in County"-Identify the Jurisdiction(cilylcounty)where you are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> VPublic 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: —t VU/-L' C <br /> ❑ 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 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: _ L <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.cdph.ea.aovloroaramslPaaeslfdbCottaaeFood.asox <br /> 4 of <br /> EHD 16-27 6/29117 CFO REGIPERMrrTING FORM <br />