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SAN�v OAQUIN <br />COUNTY <br />Environmental Health Department <br />Example: <br />MADE IN A HOME KITCHEN <br />Permit N: 12345 <br />Issued hl county: Counly nnnae <br />Chocolate Chip Cookies With walnuts <br />Sally Baker <br />123 Cottage Food Lane <br />Anywhere, CA 90),XX <br />Ingredients: Enriched flour (Wheal Dour, niacin, reduced iron, thiamine, <br />ntononiltate, riboflavin and folic acid), butter (milk. snlQ, chocolate drips <br />(sugm chocolate liquor, cocoa butter, butterfat (milk), %"Iran$, sugnr, eggs. <br />salt, artificial vanilla extract, baking soda. <br />Contains: %'hent, eggs, ndtl4 soy, unirmis <br />Net 1V6 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 />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 />'(Tesfing frequency for transient Non -Community Water Systems after initial testing) <br />❑ Bacteriological Test (quarterly'): <br />❑ Nitrate Test (yearly"): <br />❑ Nitrite Test (every 3 y <br />-Additional information may be 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: <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 Informatlon see CDPH website www.cdph.ce.noviarogramalPages/fdbCottaaeFood.asox <br />4 of <br />EHO 16-27 6/29/17 CFO REG/PERMITTING FORM <br />