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S ` N,,J µ0 )( Q I IJ I IN <br /> Environmental Health Department <br /> —�1-COUNTY <br /> Example: <br /> MADE INA HOME IQTCHEN <br /> Permit N: 12.45 <br /> Issued In comity: County risme <br /> Chocolate Chip Cookies With Walnuts <br /> Sally Baker <br /> 123 Cottage Food Lave <br /> Auywhere.CA 90'M- <br /> Ingredients: Enriched floe(Wbmt flour.niacin,reduced iron.thlftlmue, <br /> arononitrate,riboflavin and folic acid),butter(milk.sail).chocolate clips <br /> (sugar,chocolate liquor,cocoa butter,butterfat(milk). walnuts,sugar.eggs, <br /> sah,artificial vanilla extract bakiue soda. <br /> Contalms:Wheat.eggs,milk soy,walnuts <br /> Net WL 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 /> O�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)as/ <br /> Name of Public Water System or Community Services District: e--Y"kr15OiJ fli GIW OA� t{ <br /> ❑ Private Water Supply", Identify the source(well,spring, surface,etc.): r <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 Jurlsdkbon, h ,l ,( <br /> B. Food Processor Course: Initial if you agree to abide by the following: as W\ <br /> Within 3 months of being approved to operate by the Environmental Health Department, please provide proof <br /> of completion of the Cal'Ifomia Food Handler course in lieu of the California Department of Public Health(CDPH) <br /> food processor course. <br /> For more information see CDPH website www.cdoh.ca.uovloroorams/PaueslfdbColtaceFOod.asm% <br /> 4nus <br />