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SA N J O A Q U IN Environmental Health Department <br /> COUNTY - - <br /> Example: <br /> NIADE IN A HODIE KITCHEN <br /> Permit h: 12345 <br /> Issued III county: County panne <br /> Chocolate Chip Cookies With walnuts <br /> sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere.CA 90S.C\ <br /> Ingredients: Enriched flour 011heat hour.uiaciu,reduced iron,thiamine, <br /> mououitrate.Iiboflavin and folic acid),butter(milk.salt),chocolate clops <br /> (sugar.chocolate liquor,cocoa butter,butterfat(milk), walnuts,sugar,eggs. <br /> sah,artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,nillk,soy,uvalnuts <br /> Net W11.3 oz.(85,049g) <br /> Note:Forthe"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 Tracy <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: <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 <br /> (CDPH)food processor course. �(_,'d \ vJ� - e X.n 1 , 2 <br /> For more information see CDPH website www.cdnh.ca.aov! rotarams/Paaes/fdbCottaoeFood.asox U <br /> 4of5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />