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Example: <br /> MADE IN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With Wahnrts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Artywltere,CA 901' <br /> Ingredients: Enriched flour(Wheat flour,niacin,reduced iron,thiautiue, <br /> mouor ihnte,riboflavin and folic acid),butter(milk,salt),chocolate clips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk), walnuts,sugar,eggs, <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,mink,soy,walnuts <br /> .Net Wt.3 oz.(85.O49a) <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 /> RPublic 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 <br /> Department immediately. <br /> 7, Water Source: <br /> Pease'Identify the water source to be used in Cottage Food Facility(check one box) <br /> 9-frame of Public Water System or Community Services District: 64-6 4 <br /> 'm oL^+eLa'_ <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 /> f <br /> "Additional information maybe 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 <br /> provide proof of completion of the required California Department of Public Health (CDPH) food <br /> processor course. <br /> For more information see CDPH website www.cdoh.ca.-gov/pro-rams/PagesifdbCottageFood.aspx <br /> EHE 16-2711612014 3 CFO REGIPERMIITING FORM ! <br />