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r Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign IneHpprr-a91W. • t <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) StPTAGE M <br /> g . ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> hereby m de tc. I on iness in the jurisdictional area of n c <br /> Joaqui `I HPalD'istr1 <br /> 1 Ap'pI i cart <br /> HAddress <br /> Business Name (DBA) ST <br /> Address <br /> z Owner <br /> a <br /> Firm Partners, Addresses and Te naNers <br /> Emergency Telephone No.Business Telephone No. R� <br /> • l <br /> a Contractor Licence No. Date <br /> Title <br /> �Applicants Name (Print I <br /> Please check Applicable Category (1-7)-and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) CAL. Lic-nse Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> i No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> i+ 3- ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name �'" W <br /> Test Date/Ti�m�e� <br /> Test Location lJ�"r <br /> I 4. 11 SANITATION PER _ / <br /> Job Add /Locatio �� O� <br /> S Owner /e' Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑'PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW PAIR,: ❑ OTHER CA <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <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 /> �ut� ` t <br /> �2 <br /> �'gTc.ic.. 1� S <br /> ry <br /> dance with San Joaquin County <br /> I hereby certify that I have a red this application that the work will be done in accor <br /> ordinances, state law r sand regulations <br /> n Jo On Local Health District. <br /> APPLICANT'S SIGNATURE <br /> _77— <br /> FOR <br /> `FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑-ANNUALLY -❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &ReceivedREMITuiy 31 <br /> f gpgE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> p <br /> FEE L , <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER60- iM <br /> �l <br /> Received by Date <br /> Receipt No- Permit No. issua ce Da a Mailed Delivered <br /> 161 E.HAZ£LTON AYE.,P-O:Box 2009 STOGxTON,CA 95201 <br /> APPLkCANT—•RETURN ALL COPIES 70:� -ENVIRONMENTAL'HEALTH PERMIT/SERVICES '. , <br />