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w Applications Will Be Processed When Submitted Properly Completed, Be Sure To Sign The Application. <br /> ` ZhaLv C.�-r� x � APPLICATION <br /> (For Non-Transierable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SPTAGE <br /> LIQUID WASTE <br /> Application i reby made to garly on bust s in e I r'sd' ional area of the San Joaquin Local Health District <br /> C J r <br /> H Business Name (DB Addre 4e5104 <br /> Y a Owner ddress <br /> 1 Firm Partners, Addresses arj.,d Telephone Numbers dr <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print} Title Date <br /> Please check Applicable Category(1-7) and Fill in the Required Inrmation <br /> 1. 1:1PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH V HICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> ' \Description{Make/Yr., Color) c� <br /> t <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> i Capacity k Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> s 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No, of Chemical Toilets Stored <br /> k 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Tes.Date/Time <br /> 4. ❑ SANITATION PERMIT <br />` Job Addr s ocati n <br /> Ower y Address <br /> SEP C T NK ❑ SPO �EACHING FIELD ❑ PACKAGE PLANT 1q ,V$$ <br /> P ❑ PER NT ❑ TEMPORARY ❑ NEWGrREPAIR ❑ OTHER a ` -7 7 ;/ �//�^,_4 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Z O { <br /> j' Type Construction Disposal Site <br /> I 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 /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> t SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> y � <br /> r I hereby certify that I have prepared this application and that the work will be done in accordance w' foaqwn un t - <br /> c ordinances, state laws, and rules regulations of the SaqJopquin Local Health District.- <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY•. •, <br />�- Feeeli Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ! REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE. CHECKED <br /> AMOUNT <br /> FEE 5 yl ' 00 <br /> ` LESS <br /> PRORATION , .. <br /> v PLUS <br /> PENALTY <br /> OTHER 2 - - <br /> OTHER I' <br /> I <br /> ReceivedbyDate Receipt No, Permit No. - IssuanV Datd Mailed Dbsivdretl - _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES -- - 1601 E.HAZELTON AVE.,-P.O.Box 2009 STOCKTON,CA OS201 -' <br />