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r Applications Will Be Processed When Submitted Properly Completed. Be Suret&W9n Tltes-ftpLL��pliij; 1983 <br /> APPLICATION a� <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SAN <br /> LIQUID WASTE - 14EAL <br /> Applicata is hereby ade to c rry on business in the jurisdictional area of the San Joaquin-Local Health District c <br /> rn Business Name (DBA)M��f-+ 91'X'Qr Address 3� <br /> r a Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> E a Business Telephone No. �'��� / Emergency Telephone No. <br /> Contractor Licence No. 3-7-7 3S9 <br /> L Applicants Name (Print) lhob,,d 5 Title . - Date a" 7" 93 <br /> I Please check Applicable Category (1-7)and Fill in the Required Information <br /> k 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) ' <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Liccn:e Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location 'Test Date/Time <br /> 4. ❑ SANITATION PERMIT p� <br /> Job Address/Location <br /> Owner Address E — ' <br /> IVSEPTIC T NK ❑ CESSPOOL girLEACHING FIELD Gr§EEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY 21NEW ❑ REPAIR ❑ OTHER <br /> ( <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> t Type Construction Disposal Site <br /> I' No. of Units Equipment Storage/Cleaning Location(s) <br /> Y - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I ` <br /> f_ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ang rules and regula ons of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X , r <br /> i <br /> Y <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $. REMIT <br /> BASE EXPLANATION DATE REMITTED AMOUNT OUE CHECKED <br /> PATE <br /> • AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER -Z�•-,� �. <br /> 1 <br /> OTHER <br /> Received by - Date Receipt No. Permit No. Is uance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST.00l 95201 <br />