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MADE INA HOME KITCHEN' <br />Permit n: 123 <br />Ivveed In county: County name <br />Chocolate Clip Coolies 11'ith Walnut, <br />Salh' &Hier <br />C? Conaw Food Lane <br />Anssrhme. CA 90X\ <br />Ingredient: F uichtd Ilan iWheat floln. nnacuh, teduced rhea, duanune. <br />nanxwinorc, ndo0mmh and folic acid). buret. milk. .alt 1. cluvolate clulx <br />Unna. chocolate lep". cocas burn, bunerfat I nulk u. «ahnus. wgar. eggs. <br />,alt. amfhcial %widla eceaet. baking "in. <br />Contains: Whest. egg% milk vey, walnut <br />Net \\'t. ) oz. l&S.049g) <br />Note: For the "Issued In County'- Identify the/udsdichon (citylcounry) where you ata obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />Wublic Sewer Service <br />❑ Private Septic System <br />In the event of septic system failure or plumbing problem. you are required to notify San Joaquin County Environmental Health Do03rtment <br />immediately. <br />7. Water Source: <br />Pease Identify the water source to be used in Cottage Food Fact* (check one box) <br />Name of Public Water System or Community Services District: Gtr a L d c�l <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 />Ail 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 />z —Additional information maybe required if food is prepared from a home win a private water supply — check wit local jurisdiction. <br />il. 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.w.aowprooramdPooesMbCottsaeFood.asox <br />