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SAN JOAQUIN <br />Example: <br /> <br />\I.-DI IN .1110 \ M I (111.: \ <br />Permit P: 12345 <br />Issued in county; County name <br />Chocolate (hip Cookie. With Walnuts <br />Bakei <br />123 ( ottage Food lime <br />A10% lone. (.N 90.XXX <br />Ingredienh: Emiched liii Wheat !loin niacin. reduced lion. thumune. <br />Illonollitiate. nbtl1,ii iii iiil folic acid). bullet imilk. salt). chocolate clops <br />"Igal•Ii jth I coi.o.i hotel bum:1th! multi) walnul slr.2.11 <br />salt million' vanilla evn act ltaktng ,oda <br />(ontains: W.lient. eggs, milk Allot% <br />Net IN I. 3 iv/. 05.049g) <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 />Ea Public Sewer Service fl 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 />g Name of Public Water System or Community Services District: Tcc-cu <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 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 />0 Bacteriological Test (quarterly*): <br />0 Nitrate Test (yearly*): <br />0 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: <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/proarams/Pages/fdbCottageFood.aspx <br />4 of