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SAN tHAOUIN <br />—COUNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME IaTCHEN <br />Permit 0: 12345 <br />Issued In. county. County name <br />Clsombre Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food [ane <br />Anywhere. CA 90.-M <br />Ingredients: Enriched flag (Wheat Bau. niacin, reduced iron. thiamine. <br />monooinnm, riboflmin and folie acid), butter (mil. snit). chocolate chips <br />(sugar, chocolate liquor. cocoa butter, butterfat (mil), walrus, sugar. eggs4 <br />salt. artificial vanilla extract, baling sods. <br />Contains: Wheat. eggs, milk say. walnuts <br />Net WL3 or-(li5.W9g) <br />&fC For the'Issued in Couny - Idenfify the furisdWon (a7ykounW whore you are obtaining approval. <br />G. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />WPublic Sewer Service <br />❑ Private Septic System <br />In the event of septic system failure or plumbing problem, you are required to notify Ban Joaquin County Environmental Health Deparamnt <br />immediately. <br />7. Water Source: <br />Pease Identify the water source to be used in Cottage Food Facility (check one box) <br />Id Name of Public Water System or Community Services District 1t act u). a PDf`.fffWYT <br />❑ Private Water Supply", Identify the source (well, spring, surface, etc�— <br />Private Water Supply. initial Wafer Quafity 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 tab, date 8 <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 b 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 we CDPH website www.adohaaaov/aroanmslPawsndbCothoeFood.asox <br />4of5 <br />EHD ie -27 60117 CFO REGIPERMRTING FORM <br />