Laserfiche WebLink
SAOAQUIN <br />—COONTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit #: 12345 <br />Issued In counh' County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Connee Food Line <br />Any%vhere. CA 90X.X—C <br />Ingredients: Enriched flour (1lgtem flour, niacin, reduced iron. tlunmine. <br />mononitrate. ribogavin and folic acid), butter (nulk, salt). chocolate chips <br />(sugar. chocolate liquor, cocoa boner, bmrerfat (nliik), 1lalnuts, sugar, eggs. <br />salt. artificial \nnilla extract, Liking soda. <br />Contains: Wheat, eggs, milk, soy, wvolnuts <br />,Net Wt. 3 oz (85.049g) <br />Note: Forthe `Issued in County"- Identify the)udsdiction (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 />L� 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 />&N Name of Public Water System or Community Services District: 11310Sk 1\/V1L414ge11/1UVt <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 y <br />—Additional information may be required if food is prepared from a Mme with a private water supply —check velar local Jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: N • `J <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.ca.aovloroaramslPaaeslfdbCottagefood.aspx <br />4 of <br />EHO 16-27 6/29/17 CFO REG/PERMITTING FORM <br />