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Example: <br />BIG CAKE BAKER <br />Stockton CA 95209 <br />Perm V* 012345 <br />Issued in: San JOaqu in (Aunt., <br />Chocolate Chip Cookies with Walnuts <br />Ireredoeres. Enrictled flour !wheat flour, neon, reduced iron thiamine, morioncrace. °belay, r• <br />ar fdic ace', butter trrrk, salt, chocolat* chops (sugar, chocolate lipLor, cocoa bt.ster. tutter <br />waJnuts, sugar, eggs, salt, artifictal carac, baking soda <br />Contains: Wheat, milk, eggs, soy, walnuts <br />Made in a home kitchen <br />Net Wt. 3 oz. (85.05g) <br />?Vote: For the issued in County" - identity the MI9:100011 (oity/county) where you are oblarnIng approval. <br />Disposal of Waste: <br />Please check what type of treatrnert is used to dispose of waste <br />r]: Public Sewer Service : Private Septic System <br />r It o event of septic system failure or pkinlbing problem, you are reouiree to cote)/ San Joaquin County Environmental Health <br />Department immediately <br />Water Source: <br />Pease identify the water source to be used in Cottage Food Facility (check one box) <br />0 Name of Public Water System or Community Services District: <br />0 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 rmst 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 />*(resting frecluer cy for transient Non-Community Water Systems after initial testing) <br />0 Bacteriological Test (quarterly*); <br />0 Nitrate Test (yearly*); <br />4 CFO REG/PERMITrING FORM END 16-27 609/2023