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SAN.JDAOUIN <br />—COtJNTY— <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit #: 12345 <br />Issued In county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food lane <br />Anywhere. CA 90\.'X11 <br />Ingredients: Enriched flow' (Wheat floor. niacin, reduced troy thiamine, <br />mononitrate, riboflavin and folic acid), Miner (milk, salt), chocolate chips <br />(sugar, chocolate liquor, cocoa Miner. butterfat (rtilk), Walnuts. sugar, eggs. <br />salt. artificial vanilla extract, baking soda. <br />Contains: wheat, eggs, mal:, soy, walnuts <br />Net wt.3 oz (85.049g) <br />Note: For the "Issued in county- Identity the jurisdiction (city/cou*) where you am obtaining approval. <br />6. Disposal of Waste: <br />Please check what type of treatment is used to dispose of waste <br />1)-d 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 r� <br />® Name of Public Water System or Community Services District: Loo- OP <br />❑ Private Water Supply", Identify the source (well, spring, surface, etc.): <br />Private Water Supply: Iniffal Wafer 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 />"Additional information may be required if food is prepared from a home with a private water supply — check with local jurisdiction. <br />8. Food Processor Course: Initial if you agree to abide by the following: J1L1� <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 (CDPH) <br />food processor course. <br />For more information see CDPH website www.cdoh.ca.gov/programs/PagestfdbCoftagoFmd.aspx <br />