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SAN JOAQUIN <br />cOUNTY <br />Environmental Health Department <br />Example: <br />MADE IN A 11011EE 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 90XXX <br />Ingredients: Enriched flour (Wheat flour, niacin. reduced iron. thiamine. <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 vanilla 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 />P/ease check what type of treatment is used to dispose of waste _ <br />11 Public Sewer Service LI 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 />Peaie- Identify the water source to be used in Cottage Food Facility (check one box) <br />(21 Name of Public Water System or Community Services District: 0-41 <br />LI Private Water Supply**, Identify the source (well, spring, surface, etc.): <br /> <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 />[1 Bacteriological Test (quarterly*): <br />LI Nitrate Test (yearly*): <br />LI 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: ISIM <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 De artment of Public Health (CDPH) <br />food processor course. aejr+-1.n,ffter 04.2 etrry\f),(.2.41 rryl <br />i 1 <br />. , ,.., .., , <br />For more information see CDPH website wWw.cdph.ca.govIprograms/Pages/fdbCottageFood.aspx <br />4 of 5