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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. E�Ttfl, <br /> u APPLICATION <br /> 4 (For Non-Transferable, Revocable,and Suspendable) $EPTAGE I' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA)_McDOTL3lC1 S6pt1Ce Tank-Service Address 4643 Hildret-h bane <br /> ( a Owner- '_R. MCDOtla1'C� Address,. . <br /> a Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No'.+ , 3 1" 049 7 Emergency Telephone No. 957--4027 <br /> Contractor Licence No.L 3 08 17 1 <br /> �Applicants Norrie.(Print) T R. McDonald Title Ow-� Date �/] <br /> Please check 4plicabie Category(1-7) and Fill in the.Required Information. U1 <br /> I. ❑ 'PUMPER VEHICLE PERMIT REGISTRATION,(FOR EACH VEHICLE) <br /> For July 1, June,30, 19 Disposal Sites S <br /> Description(Make/Yr., Color) <br /> L Serial No. CAL. License No. J CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No.-. <br /> I 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 /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT \ <br /> Job Address/Loca ion L <br /> Owner <br /> SEPTIC TANK ❑ CESSPO L LEACHI G FIEL ❑ EP GE PIT ACKAGE PLANTIN <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑°REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Ju a 30, 19 <br /> Type Construction Disposal Site t <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> k Plant Location <br /> f 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 /> 1 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., and rule d re ulations o San Joaquin Loc Healt istrict. <br /> APPLICANT'S SIGNATURE X <br /> f <br /> ?4� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY El PER UNIT ❑ PER SITE El EACH El January 1 &Received By January 31 El July 1 &Received By Jufy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED - .AMOUNT <br /> k FEE Liz <br /> LESS <br /> PRORATION <br /> PLUS ` <br /> PENALTY <br /> OTHER <br /> OTHER a <br /> '---7 It ¢ <br /> Received by Date Receipt No permit No. - issunceadate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA$5201 <br />