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r Applications Will Se Processed When Submitted Properly Completed. Be SureTOsign ineAppllcauon <br /> APPLICATION S <br /> (For Non-Transferable, Revocable, and 5uspendable) $EpTAGE <br /> ENVIRONMENTAL HEALTH PERMIT �. <br /> LIQUID WASTE <br /> Application is hereby rmaad�e to c rry on business in the j risdictional area of th San Joaquin Deal Health District <br /> y Business Name (DBA) ��c � T �L L 3 fNC-� 10 G _ Address <br /> C2Address 5 o LU--- C- <br /> 2 <br /> Firm Partners, Addresses a lephone Numbers n� <br /> a. Business Telephone No. Emergency Telephone No. <br /> Gontractor Licence No. <br /> �Applicants Name (Print) - t-- - Title Date <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) <br /> Serial No. CAL. License No. - YCAL. License Renewal No. <br /> Y <br /> Ca acit Gal., Weights & Measures No. ' <br /> Capacity n <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD J <br /> For July 1, June 30, 19 1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3.r-❑wPERCOLATION TEST - *-Y -3:' <br /> R.S. or R.C.E. Name t R.S. or R.C.E. No. <br /> Test Location Test Date/Time s <br /> A. ❑ SANITATION PEIT r <br /> 41 <br /> Job Address/Location 5 -S, S E �+ <br /> i Ownet\� G� �r ` t`'1 Address <br /> ls�� <br /> ❑ SEPTIC TANK ❑ CESSPOOL -LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW XREPAIR ❑ OTHER { <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 <br /> Operator Name Where Certified -- -------- - <br /> k r <br /> Plant Location , <br /> Plant Capacity No. Units Served <br /> i 4 f s <br /> 7. ❑ LAUNDRY For July 1,' June 30, 19 l <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> t <br /> 1 hereby certify that'] have prepared this application and that=the work will tie done in accordance with San Joaquin County <br /> ordinances, stat la d rules and gulatio s of th San Joaquin Local-Health District. <br /> k. <br /> APPLICANT'S SIGNATURE <br /> Y � <br /> ! FOR DEPARTMENT USE ONLY <br /> r Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 July 1'&"Received try July 31 <br /> + REMIT <br /> Ik BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE � CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> ' <br /> LESS <br /> PRORATION y PRORATION 'n. <br /> -PLUS <br /> 4i <br /> PENALTY _ <br /> } OTHER <br /> �* OTHER <br /> ' Permit No. Issuance Date Mailed elsv <br /> Received by Date Receipt No <br /> ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES .. , -11601.E.HAZELTON AVE.,P.O.Box 2009. ST N, A 95 0"x <br />