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Example: <br /> BIG CAKE BAKER <br /> Slot kton CA 95209 <br /> Perri it#012345 <br /> Issued in Sall Joaquin County <br /> Chocolate Chip Cookies with Walnuts <br /> lrtmedie-ms Enrichod f laur twheat fluor,niacir,reduced iron,thiamine,mononitrate,riboflavin <br /> and folic midi,butter(milk,salri- h late chips(sugar,chocolate liquor,rowabutter,buttarfvt <br /> smear,egrs sal arnfnalvart ila extract,baking s,oW <br /> Contains: Wheat, milk,eggs, soy, walnuts <br /> Made in a home kitchen <br /> Net Wt. 3 oz. (95.059) <br /> Note:For the lssuerd in Catlnry" identify the jurisdiction{city/county)where you are obtaining approval, <br /> 6. Dis osal 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 <br /> Department 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: d1rY pricy <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 /> q CFO REGIPERMIT 1 ING FORM <br /> FHD 16-27 6/2912023 <br />