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SAN :JOAQUIN <br />1, OU r�lTV <br />Environmental Health Department <br />Example: <br />.MADE I\':1110\IF: 6tTCIlES <br />Prrndly; ID45 <br />bsonlfo c'unh': Caum,., <br />Cboccdmc ('lup Ccrok" 11'ah 11'1...11, <br />Shcy Hnkcr <br />123 C Chace Food tans <br />An)wluTc. CA 90XXX <br />Ingravllents: is"'l al dao O\ IM11 from. nlmdv, teducecl iron. dumNne. <br />uwuouitrare, dbollatin and relic acid), buncr (milk, sut). cIIMrlme clues <br />(sngu, chocolate liquor. cocoa bun,. bunetfill (mil4 ssalunts. suvan eggs. <br />salt, ,"ficial t1fulla csmct, baking sah. <br />Cantalns: RTeul. eggs, ndlk sot', walnuh <br />\e1111. 3 oz. (85.049g) <br />tote: Fa 1 Issued m County' - Id-* thejurlsolkhon f aty/county) where you are obtaining approval <br />6. Disposal of Waste, <br />Ffeag�check what type of treatment is used to dispose of waste <br />L-.I/Public Sewer Service ❑ Private Septic System <br />M ed1 dsaptic system failure or plumbiriatary,g problem, you are requinal to notify San Joaquin County Environmental Hean Department - <br />7. Water Source: <br />7Pea 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 />", Identify the source (well, spring, surface, etc.) <br />❑Private Water Supply <br />Private Water Supply: Initial Water Quality Results <br />Check boxes below A 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 pmvided next to type of test _ <br />'(Testing frequency fortransient Non -Community Water Systems afterinitial testing) <br />❑ Bacteriological Test (quarterly): <br />❑ Nitrate Test (yeady7:` <br />❑ Nitrite Test (every 3 years. <br />"Add4t pl information may be mqured if food is prepared fmm a home with a private water supply - check with local jLmirA ctlon. <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.00vlproatamypaoe5 MbCottaoeFond asox <br />EMD 16-27 629/17 <br />4of5 <br />CFO REGIPERMITTING FORM <br />