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SANN J O n Q I � I N Environmental Health Department <br /> JJ t-i ICS!0 U IN-1T YlJ '�1 <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walnuts <br /> Salk•Baker <br /> 123 Cottage Food Lane <br /> A w where.CA 90X1LX <br /> Ingredients: Emiched flour(Wheat flour.niacar.reduced iron.thiamine. <br /> mononitrate.riboflavin and folic acid).butter(null:,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 sod•,walnuts, <br /> Net tit t.3 oz.(85.049g) <br /> Note:For the"Issued in County"-Identify the Junsdickm(citykAxwdy)where you are©btarn V approvaC <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> ZI 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 DepaMnent <br /> immeadiately. <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: r <br /> ❑ Private Water Supply"', Identify the source(welt, spfing, 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:� t <br /> Within 3 months of being approved'to operate,bythe Environmental Health Department, pl'eese•pr©vide-proof <br /> of completion of the California Food Handier course in lieu of the California Department of Public Health <br /> (CDPH)food processor course. <br /> For more information see CDPH website www.r-doh.ca.aov/pro-grams/PaaeslfdbCottaaeFood.aAm <br /> 4 of 5 <br /> EHD 16-27 6/29/17 CFO REG/PERMITTING FORM <br />