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SHAWN <br />—COU NTY— <br />I <br />Example: <br />MADE IN A HOSE IOTCHEN <br />.Permit #: 12305 <br />Issued in county: County name <br />Chocolate Chip Cookies With walnuts <br />Sally Baker <br />123 Cottage Food Line <br />Aiiywheie. CA 90XXX <br />Environmental Health Department <br />Ingredients: Enriched flour (Wheat flour. nunchs. reduced iron, tltiamine. <br />niononinate, riboflavin and folic acid). butter (milk. salt), chocolate clips <br />(shear, chocolate liquor. cocoa butter. butterfat (milk). walnuts, shear. eggs, <br />salt, artificial vanilla extract. baking soda. <br />Contains: NN%eat, eggs, milk, soy, walnuts <br />Net Wt. 3 oz. (85.049g) <br />Note: For the Issued in County'- Identify the jurisdiction (city/county) where you ale 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 />P se Identify the water source to be used in Cottage Food Facility (check one box) <br />`Jame of Public Water System or Community Services District: I'm 6-W o; L0c11 (IWoyly� <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 />B. Food Processor Course: Initial if you agree to abide by the following: H • K <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.w.novli)ro_qmmsIPages/fdbCottageFood.aspx <br />0 of <br />END 16-276/29117 CFO REGIPERMrFNNG FORM <br />