Laserfiche WebLink
SANp1QAQUIN <br />—COU NTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit tl: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies Wish Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Any%vhere. CA 90'.S,%C <br />Ingredients: Muiched flour (Wheat flow, niacin, reduced iron. thinmine, <br />mononitrate. riboflavin mud folic acid), butter (wilk, snit), chocolate clips <br />(sugar, chocolate lieptor, cocoa bxma, butterfat (milk), %valnuts, sugar, eggs, <br />salt. artificial vanilla extract, baking soda. <br />Contains: N'hent, eggs, milk, soy, walnuts <br />Net Wt. 3 oz (85.049g) <br />Note: For the 'Issued in County'- Identify the Jurisdiction (citykounty) where you are obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />322Y.Public Sewer Service ❑ Private Septic System <br />In the event of septic system failure or plumbing problem, you am 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.): <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 />❑ Bacteriological Test (quarterly'): <br />❑ Nitrate Test (yearly'): <br />❑ Nitrite Test (every 3 years`): <br />"Additional Information may be required if food is prepared from a home with a private ester supply — check with localjudsdlctlon. <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.edoh.co.aovlorogramsMaoestfdbCottaneFood.asox <br />4 of <br />EHD 1627 6/29117 CFO REWERMIfTING FORM <br />