Laserfiche WebLink
SAN10 A Q U I N Environmental Health Department <br /> --C O U N T Y --- <br /> Example: <br /> -NLA,DE IN A HOME KITCHEN <br /> Permit#: 12313 <br /> Issued in county: County name <br /> Chocolate Chip Cookies With NValnuts <br /> Salle Baker <br /> 1_13 Cottage Food Lane <br /> An%lvhere,CA 90-KXX <br /> Ingredients: Emiehed flour(Mieat flour,triacur.reduced irate,thiamine. <br /> rnononinate,riboflavin and folic acid),butter(milk,salt).chocolate clips <br /> (sugar.chocolate liquor.cocoa butter.butterfat hnilk)_ tvalnus.sugar.egg,. <br /> salt,artificial vanilla extract,baking soda. <br /> Contains:Wheat,eggs,milt:,soy,walnuts <br /> Net NN't.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 /> Please check what type of treatment is used to dispose of waste <br /> rEA-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 /> �4Name of Public Water System or Community Services District: <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. <br /> For more information see CDPH website www.cdph.ca.coviprosCrams/Paces/fdbCottaceFood.aspx <br /> 4;)r5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />