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S A N pJ O A Q U I N Environmental Health Department <br /> —COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> permit#: 17115 <br /> Issued In mums•: County name <br /> Chocolate Chip Cookie,With Walnuts <br /> &ill)'Bnkcr <br /> 173 Collage Food Isle <br /> An}lvlrcre,CA 90NNN <br /> Ingmllemb: Earkhed gav(Wheal Bom,niacin,lednrnl iron.Ihimnihc, <br /> muhanitmte.rikotimin and folic acid),ranter(milk silt),chocolate chips <br /> (sugmr,dwoolme liquor,cocoa butter,bnmerfnt(milk), mhaim sugar,eggs, <br /> Sall.mtificial smtilla extract.baking sokkl. <br /> Contnins:Wheal,eggs,milk,soy,o'ninuts <br /> Net Nt.J oL(85,0498) <br /> Note:For the'Issued in County'-Identify the jurisdiction(city/wunty)where you are obtaining approval. <br /> G. Disposal of Waste: <br /> Pleasp check what type of treatment is used to dispose of waste <br /> 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 /> Pea a Identify the water source to be used in Cottage Food Facility(check one box) <br /> Name of Public Water System or Community Services District: MQ0`1":4CS u <br /> C]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 /> "Addifionsl information may be required if food is prepared from a home with a private water supply—check with localjurisdiction. <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 mom information see CDPH viebsite www odeh m.noyfprwmmslPaaesndbCottaaeFood.wnx <br /> 4 of <br /> EMD 1647 W9/17 CFO REGIPERMfRING FORM <br />