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SAAI _JO AHQ I I I AI Environmental Health Department <br /> - <br /> COUNTY— <br /> Example:OU NTYU—f Y <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued In count-: Count).nate <br /> Chocolate Clip Cookies With Wahmas <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90-IM <br /> Ingredients: Enriched flour(R1xat dour,niacht.reduced iron,thiamine. <br /> moriouitrate,riboflavin and folic acid).butter(milk.sal).chocolate clips <br /> (sugar,chocolate liquor..cocoa butter,butterfat(milk). walnrrts,sugar.eggs. <br /> salt artificial vanilla extract baking sofa. <br /> Contains:RLeat,eggs,milk,wy,walnuts <br /> Net 11 t.3 oz(85.049g) <br /> Note_For the'Issued in County"-Identify the jun'sdiclion(city/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 /> LI/Public 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: C( ht D r— S TDCKTON r GA <br /> ❑ Private Water Supply—, Identify the source (well, spring,surface, etc.): <br /> Private Water Supply:Initial Water Quality Results <br /> Check boxes below if initial water testing has been completed. <br /> All tesfing must be done ata 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 it food is prepared from a Mme 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.cdph.cagovlprogmms)PanesffdbCottageFood.aspx <br /> EHD 1627 6/29/17 CFO REGrPERMFMNG FORM <br />