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SAN aJ O A Q U I N Environmental Health Department <br /> —COU NTY <br /> Example: <br /> .%L%DE IN A HOME KITCHEN <br /> Permit H: 12345 <br /> Issued in county: Comity name <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> L;Cottage Food Lane <br /> Anywhere.CA 90.NXX <br /> Ingredlents: Enriched flaw(Wheat four,niacia.reduced iron.tltiantue, <br /> mononitrate.riboflavin and folic acid).butter("IL salt).chocolate chips <br /> (shear.chocolate liquor.cocon butter.butterfat(Hulk), wahhas.sugar.eggs. <br /> salt.artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz(85.049g) <br /> Note:For the'Issued in County -Identify the jurisdiction(city/county)where you are obtaining approval. <br /> 6. Disoosal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> ❑ Public Sewer Service [[4 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: <br /> ❑ Private Water Supply", Identify the source(well, spring, surface, etc.): Neik1 <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& <br /> results in space provided next to type of test. <br /> *(Testing frequency for transient Non-Community Water Systems after initial testing) <br /> E�] Bacteriological Test(quarterly*): <br /> LSIt1n` G <br /> Nitrate c,,,e �1,`1 <br /> a,,tAl �� [oc 6k �na��S► S <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: <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.cdoh.ca.aov/oroaramslPaaes/rdbCotfaaeFood.asox <br /> 4 of <br /> EHD 1627 0/29/17 CFO REGIPERMFUING FORM <br />