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: Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> • (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT I SEEPAGE <br /> i� LIQUID WASTE E <br /> Application i Ieby maftto carry on business in the ju isdictional area of the San Joaquin Local HealtDpistrict <br /> FAddress—�d� �--2 L-1 <br /> Business Name ( A} <br /> z Owner a�. Address <br /> -C J <br /> Firm Partners,Addresses and Telephone Numbers <br /> CL Business Telephone No. f D� Emergency Telephone No. <br /> QP <br /> � Contractor Licence No. �— Ifi <br /> 4K 'I Date <br /> L Applicants Name (Print} = u Title <br /> Please check Applicable Category (1-7)and Fill In the Required nformation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19[ Disposal Sites # <br /> ` Description(Make/Yr., Color) �I <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. l� <br /> i Equipment Parking Address p, <br /> 2. ❑ PUMPER;YARD A <br /> For July 1, — June 30,191 <br /> No. of Vehicles Stored 19 No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ll r <br /> R.S. or R.C.E. Name { R.S. or R.C.E. No. a <br /> Test Location I Test Date/Time 11 <br /> i4 ❑ SANITATION P <br /> ERMIT 1 <br /> 1 1 <br /> JobAddrss tion i <br /> d f- <br /> O <br /> S <br /> wn r, 4 Address lLe n�11 Q <br /> rc PTICTANK`}. ❑ CESSPOOL ' ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> RMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction ik Disposal Site <br /> No. of Units t Equipment Storage/Cleaning Location(s) �r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> ` Operator Name I Where Certified <br /> Plant Location d j <br /> Plant Capacity No. Units Served if <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. t <br /> I <br /> N ' <br /> I I hereby certify that ,I have prepared this application and that the work will be done in accordance wl� San Joaquin County <br /> ordinances, state laws, and rules and regVlations of the San Joaquin Local Health District. of <br /> 1,7 <br /> APPLICANT'S SIGNATURE X Mel�z� <br /> is <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ,; ❑ PER UNIT ❑ PER SITE s ❑.EACH ❑ Janu ry 1 & ed By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANC $ M AMOUNTDU _ REMIT <br /> - BASE ,t '�EXPLANATION � E. CHECKED <br /> DATE t` DATE) REMITTED �} AMOUNT <br /> FEE <br /> LESS " r'~ � <br /> PRORATION II / °° <br /> PLUS �I <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuanc Date Mailed livered - <br /> APPLICANT—RETURN ALL COPIES TO: ,'ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />