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SAN J0A Q U I N Environmental Health Department <br /> COUNTY— <br /> Example: <br /> MADE IN_� I10\IE KITCHEN <br /> Permit#: 12345 <br /> Issand In county: Comty now <br /> Chocolate Clip Coolies With Walnuts <br /> Sally Baker <br /> l23 Cottage Food lane <br /> An3where.CA 90V, ,X <br /> Ingredients: Enriched flour(Wheat flan,niacin,reduced iron.thianine. <br /> n o fouitrate.riboflavin and folic acid).butter OnAlk.salt),chocolate chips <br /> (sugar,chocolate liquor.cocoa butter.butterfat(ustl:), wahnns.sugar,eggs, <br /> salt.artificial%midla extract,baking soda. <br /> Contains:Wheat,eggs,milk,soy,walnuts <br /> Net Wt.3 oz.(85.049g) <br /> Note:For the-Issued in County--Identify 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 /> C 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: <br /> ❑ Private Water Supply", Identify the source(well,spring, surface,etc.): �� ��S-�oek. <br /> Private Water Supply:Initial Water Quality Resuka <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 /> "Additional information may be required if food is prepared from a tome with a private water supply—check with ioc it jurisdiction. <br /> 8. Food Processor Course: Initial if you agree to abide by the following: ,-s-m <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.cdah.ca.aovloroarams/PaaesifdbCattaaeFood.asox <br /> 4 of <br /> EHO 16-27 629117 CFO REGMERMnTING FORM <br />