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SANJOAQUIN Environmental Health Department <br /> COUNTY— <br /> Example: <br /> MADE IN A HOME KITCHEN <br /> Permit#: 12345 <br /> Issued In county: County name <br /> Chocolate Chip Cookies With Walmnts <br /> Sally Baker <br /> 123 Cottage Food Lane <br /> Anywhere,CA 90.\—%X <br /> Ingredients: Enriched flour(W9teat flour,niacin.reduced iron,thitmane. <br /> mouonitmte,riboflavin and folic acid).butter(nulk,salt),chocolate clips <br /> (sugar,chocolate liquor,cocoa butter.butterfat(milk), walnuts,sugar.eggs, <br /> salt.artificial vanilla extract.baking soda. <br /> Contains:NN beat,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 are obtaining approval. <br /> 6. Disposal of Waste: <br /> Please check what type of treatment is used to dispose of waste <br /> 5 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: <br /> [&Private Water Supply—, Identify the source (well, spring, surface, etc.): VV <br /> &U Wos yrloc,5 <br /> Private Water Supp/yInitial Water Quality Results *N%%5 aNLy PSVSII! C %P"O:/S WAi'L <br /> Check boxes below if initial water testing has been completed. FoYl 1116 6201PUCTc. AN b lfui2 CE&ArAII 16 <br /> All testing must be done at a State Certified Laboratory. Either attach lab results or provide name of lab, date& 6p Su ff l40 ,45 <br /> results in space provided next to type of test. W M4f(tp k kS S4N.1176 <br /> *(Testing frequency for transient Non-Community Water Systems after initial testing) >'V¢YlytrllNb WtTh <br /> ® Bacteriological Test(quarterly*): STAC&kN ssyu1T12Be <br /> © Nitrate Test(yearly*): <br /> m Nitrite Test(every 3 years*): <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: �<6 <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.edph.ca.aovlaroarams/PaaeslfdbCottaaeFood.asox <br /> 4 of <br /> EHD 16-276/29/17 CFO REG/PERMITTING FORM <br />