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I <br /> SA N pl V Q Q V I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A IID\tE IUTCIMN <br /> permh>3: 12315 <br /> Issued to coUetr. Copnty come <br /> Cisomlae Chip Coolies A ah Walnuts <br /> Sally Ban <br /> 123 Cooage Food tme <br /> Ay`Mbff.CA 90-V'X <br /> Ing'edlents. Earkl d note(t\Lnt flow,niacin radwod ima rhiaurine. <br /> npconniaat<,nM[Ai,and folie add).lona(MilL sa4 chocohte chips <br /> (saga,c wUm liquor.coma bunt r,tunafit(®R),wlwas,str€as. <br /> sa0,srdfidal swilla esawt.babrig soda. <br /> Conlaha+:%Nb ay ergs,mak say,—Mats <br /> Nen Rt 3 oz(95.019M <br /> Nt,For the'Issued in county-Identify thejurisdxtlon(city/county)where you ere obtalnfng 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 evert of septic system failure or plumbing problem,you are required to Moll San Joaquin County Env]ronm ental 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: <br /> Ly Private Water Supply',Identify the source(well,spring,surface,etc.): <br /> Pdvato 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 lest. <br /> '(Testing frequency for transient Non-Community Water Systems after initial testing) <br /> ❑Bacteriological Test(quanedy): <br /> ❑Nitrate Test(yeady7: <br /> ❑Nitrite Test(every 3 years*): <br /> "Adddloml Infumetion may be required if food is pmpared from a horn with a pr(vale sorter 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 vmbshe www cdatt caoovlproammsfPaoesadbCottageFood.aspx <br /> 4 of <br /> EHD 16-27 629n7 <br /> CFO REGPERMI`MNG FORM <br />