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AppllcaionsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Applit:aliprf"� <br /> APPLICATION ry ° <br /> (For Non-Transferable, Revocable, and Suspe d ble) "_ <br /> RMIT SFPrA�i= <br /> ENVIRONMENTAL HEALTH PE <br /> LIQUID WASTE - `_ <br /> Application is h y ma a to car o usiness in the jurisdictional area oft S <br /> an J aquin Local Health District <br /> Business Name{DBA) <br /> c Owner • Address .� <br /> Firm Partners, Addresses and Telephone Numbers Address L =• d= <br /> ILBusiness Telephone No. Ike of. <br /> Contractor Licence No. Emergency Telephone No, <br /> LApplicants Name (Print) - <br /> Please check Applicable Category (1-7) Title Date �Z <br /> 9 and ill in th_e Required Information- <br /> 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH Jc <br /> VEHICL ) <br /> Disposal Sites E <br /> For-July June 30, 1'9 <br /> Description(Make/Yr., Color) t '^ f .• <br /> Serial No, CAL. License No. <br /> Capacity CAL, License Renewal No. <br /> Gal., Weights & Measures No { � <br /> Equipment Parking Address ' ) <br /> 2. ❑ PUMPER YARD <br /> _ <br /> For Jul "' '..�'..'�„ b-•;_..-': <br /> Y 1, <br /> June 30, 19 {,, �/ Ji ) <br /> No. of Vehicles Stored ' <br /> No. of Chemical Toilets Stored ' X__ <br /> 3. ❑ PERCOLATION.TEST <br /> R.S. or R.C.E. Name 7 <br /> Test Location R:S. or R,C.E. No. <br /> 4. IR SANITATION PERMIT Test,D''ate%Time ) <br /> i <br /> Job Addres/Location00 <br /> •p `� y <br /> Own r L ✓ <br /> ,�, A ddress Q, N r <br /> +�SEPTIC TANK ❑ CESSPOOL r <br /> BLEACHING FI'ELq SEEPAGE PIT ❑ PACKAGE PLA <br /> �ERMANENT ❑ TEMPORARY &-KtW NT <br /> 5. ❑ CHEMICAL TOILETS For July 1, dune 30;>19-, ❑ REPAIR El OTHER ;c <br /> Type Construction `? ?( �.. <br /> No. of Units Disposal Site <br /> _ 2r4 u,IPment Storage/Cleaning Location(s) <br /> s• PACKAGE TREATMENT'PL_AI T dor July 1, -June 30, 19 <br /> r f.. <br /> Operator Name <br /> Plant Location <br /> .� Where Certified ` <br /> F , <br /> Plant Capacity i <br /> 7• ❑ LAUNDRNo. Units°Served <br /> Y For JulyI -June 19,_ <br /> SIZE: ❑ Less'Than 1,000 Sq FC ❑ More Than 1,000 Sq. Ft. f <br /> .❑ DRY CLEANING, Chemicals Used/Amount/Mo. f <br /> I hereby certify that I have rr p red th s a plication and t t the-work will be done in acco nce it an Joain Count ' <br /> ordinances, state laws, - g tions of the Joaquin Lo I He th District. �' Y 4 <br /> : t <br /> APPLICANT'S SIGNATURE X <br /> L FOR DEPARTMENT USE ONLY $ <br /> Fee Is Du <br /> e: ❑ ANNUALLY PER UNIT <br /> r❑ PER SITE ❑ EACH ❑ January 1 &Receive By J n 31 t } <br /> k ❑ July'1 &Received By July 31 <br /> r BASE I EXPLANATION t BILLING REMITTANCE ° J I{ - REMIT - <br /> j--r- - DATE DATE RE D AMOUNT DUB CHECKED <br /> FEE ; tI- Cr AMOUNT { t <br /> LESS <br /> PRORATION <br /> Q —¢ <br /> PLUS <br /> PENALTY J16' d �; <br /> I <br /> OTHER ,► f ..- F. r <br /> OTHER * i <br /> Received by Date �.a <br /> Receipt No. <br /> APPPermit No. issue ce D to r <br /> APPLICANT—RETURN ALL COPIES t0: ENVIFIONMENTAL HEALTH.PERMIT/SERVICES'_' i Mailed Delivers <br /> 1601 E.HAZELTON-AYE'.,P.O.Box 20o9 STOCKTON,CA 95201 1 <br />