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SA N sJ O A Q U I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit N: 12345 . <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> SallyBaker <br /> 123 Cottage Food Lane <br /> Anywhere.CA 90X"XX <br /> Ingredients: Enriched flour(1Vheat flour.niacin,reduced iron,thiamine. <br /> nioaonihnte.ribotlavin and folic acid),butter(Milk,silt),chocolate chips <br /> (sugar,chocolate liquor,cocoa butter.butterfat(milk), walnuts,sugar,eggs, <br /> salt,artificial vanilla extract,baking soda._ <br /> Contains:Wheat,eggs,milk,soy,walnuts . <br /> Net Wt.3 oz.(85.049g) <br /> Nom,For the'issued in County"-Identify the jurisdiction(0y/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 everd ofseptic system Wm or plumbing paWem,you are required to nobly Sen Joaquin County Environmental Heam Department <br /> immediately. <br /> 7. Water Source: <br /> Pease lden*the water source to be used irk Cottage Food Facility(check one box) <br /> Name of Public Water System or Community Services District: �, <br /> ❑Private Water Supply",identify the source(well,spring,surface,etc.): <br /> Private Water Supply.InfBal Waller Quality Resuft <br /> Check boxes below if initial water testing has been meted. <br /> All testing must be done at a State Certified laboratory_ Flitter 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 /> "Addifional u formalmn may be Papered Blood is prepared from a tome with a private water supply—c hack with braijursdictioon.. <br /> 8. 00 Processor Course: Initial if you agree to abide by the following: f� <br /> ithin 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 /> Formore aftmatim see CDPH v*bsft oottasox <br /> 4 of 5 <br /> EHD 16-276129117 CFO REGIPERMrrTING FORM <br />