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SAN o'J O A Q U I N Envinnuncnlal Hc:alih Drpartmenl <br /> -- COUNTY -- <br /> Example: <br /> MADE IN A IRMI1{AIT'('IIEN' <br /> 1'urmll p: 12345 <br /> Issued In counl): Counly name <br /> Chncnlalc l'bip co4tes k%III%N III <br /> SO[,Nikel <br /> 121 Cwinw Flm,l Lane <br /> Auswhcie.CA 90SSY <br /> Ingredteoh: Emirhed flour l\1Lem claw,nlaen.Ieduari iron.Ihianlinc. <br /> monwlimte,ribothsvl nId(olio nodi.l+nner uudk.will.chacolale chgx <br /> lsgear.dwcolale lirpmr.nxea lamsti.bund[m Imdkl. MAIM,vim.t-oes. <br /> snl1.amticial e:nulla eximcl.baking smia - <br /> Conlalns:Wheal.eggs,milk soy.lsntnuls <br /> \el All.3 07.(85.II49g) <br /> Note:For the Issued In County"-Identity the jurisdiction(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 /> 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 /> (Name of Public Water System or Community Services District: �1�� o �4Avlk<u <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 /> "AtldiOnal bdormaeon may be required If food Is prepared from a home with a private water supply-check with locaijunsd0lon. <br /> B. Food Processor Course: Initial if you agree to abide by the following: CT <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 miormauon see CDPH webstlr,www.cdoh,ca.(iovlprmramstPaoes/fdbCollaueFood.aspx <br /> 4015 <br /> EHD 16276129117 - CFO REGMERMITTING FORM <br />