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SAN10 A Q U I N Environmental Health Department <br /> COUNTY— <br /> Example: <br /> U%DE IN a HOME KITCHEN' <br /> Permit M: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With walnuts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,C.A.90k"a"T <br /> Ingredients: Enriched flour(Wheat flour,niacin,reduced iron.thiounme, <br /> mononitrate.riboflavin and folic acid),butter(milk,salt).chocolate chips <br /> (sugar.chocolate liquor,cocoa butter,butterfat(milk), walnuts.sugar,eggs. <br /> salt,artificial vauilla extract,baking soda. <br /> Contains:Wheat,eggs,mill:,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 /> ® 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: City Of manteca Water <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 /> "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: D.E. <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.cdph.ca.gov/programs/Pages/fdbCottageFood.aspx <br /> 4 of <br />