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SANJ O A Q U I N Environmental Health Department <br /> COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit a: 12345 <br /> Issued In county: Comity name <br /> Chocolate Chip Cookies Willi Wnlnnts <br /> Sally Baker <br /> 123 Collage Food Lane <br /> Anywhere,CA 905XX <br /> Ingredients: Fiviched flour(\Vheatfloar.niacin,reduced iron,fiinnune, <br /> nionouihate,riboflavin and folic acid),butter(milk,salt).chocolate chips <br /> (sugar,chocolate liquor,cocoa butler,butterfnt(milk), walnuts,sugar,eggs. <br /> salt,artificial vanilla extracl,baking soda. <br /> Contains:Wheat,eggs,mlik,say,uvhmts <br /> Nel Wt.3 oz.(85.049g) <br /> Note:For the"Issued In County"-Identify the/unsdiction(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 inif9al 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.J <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,edoh,ca.gov/programs/PauesobCottansFood.a$Dx <br /> 4 of <br /> EHD 16-27 6129117 CFO REGIPERMITTING FORM <br />