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SANIJOAQUIN <br /> <br />Environmental Health Department <br />—COUNTY <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit 14: 12345 <br />Issued in county: County name <br />Chocolate Chip Cookies With Walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere, CA 90X.XX <br />Ingredients: Enriched flow (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 />Ple e check what type of treatment is used to dispose of waste <br />Public Sewer Service <br /> I=1 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 />Pe e Identify the water source to be used in Cottage Food Facility (check one box) <br />Name of Public Water System or Community Services District: ei <br />1:1 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 />LI Bacteriological Test (quarterly*): <br />El Nitrate Test (yearly*): <br />1:1 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: LV ni <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 DeRartme,nt of f1 ublic Health (CDPH) <br />food processor course. ae,r4i6,-0,em GfCM9 /Oh ayi <br />For more information see CDPH website www.cdph.ca.qo proqrams/PaqesfidbCottaqeFood.aspx <br />4 of 5