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SAN110AQU IN l:nvirr7nmrnlyd Hralih Drparlmrnt <br /> Example: <br /> NI:1pI:INA HIM IF Nil CIIEN <br /> Permlt a: 12.75 <br /> Arced In count': Count.name <br /> ('hncohic('hip('nok,es R'oh\Galina. <br /> Mlle Bake, <br /> 123('om,ec Fond I-m,e <br /> A,mvime.('A 9OXS\ <br /> Ingredients: Emielml flmu(l11em Ilona.nacin.I'Alleal irnnthiamine. <br /> nronomtmte,ribotlann and folic Heid).better I milk.callf chocolare clups <br /> (sugar.chocolate liquor.cocoa India.honedat II,III4 sswhans,wgar.eee,. <br /> salt.amGctal cnnilla extract.baking nvdn. <br /> Contains:\\Leat,eggs,milk,soy,ssalnuk <br /> Net\\t.3 oz.(85JI47g) <br /> ore: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 /> 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: 1�1�r.1 O� Ucinkr R <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 /> "Addnamal Information may be required If food Is prepared from a home with a private water supply-check with bcal)udsdictlon. <br /> B. Food Processor Course: Initial if you agree to abide by the following: C t <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.cdt)h,ca,aomior2g[LrDs/PaueslfdbCottaceFood.asox <br /> 465 <br /> EMD 76.27 6121107 - CFO REG/PERMITTING FORM <br />