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Applications Will Be Processed When Submitted Properly Completed. Be Sure To SignThe <br /> APPLICATION <br /> (�r Non Transferable, Revocable,and Suspendable) $FPTAGC <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio 's hereby made to carry on business in a jurisdictional area of the San �aquin Local Health District 2,K 17 <br /> f y Business Name (DBAddress <br /> A) ? <br /> a Owner <br /> Address <br /> Firm Partners, Addresses and Te�ephJne!Numb rs Emergency Telephone No. <br /> I a Business Telephone No. _ <br /> � <br /> Contractor Licence No. TZ <br /> Title Date �'' <br /> 11 1,11ag <br /> Applicants Name (Print). <br /> Please check Applicable Category 0-7J and Fill in the Required Informs ton <br /> 1. ❑PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> -June- 19 Disposal Sites <br /> Description.(Makee//Yr.,Coolor) .`" CAL. License Renewal No. <br /> ,+ Serial No. CAL. License No. <br /> Capacity Gal., Weights & Measures No. <br /> f Equipment Parking Address <br /> I 2.'-❑ PUMPER YARD <br /> June 30, 19 <br /> For,July 1, � <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R,S, or R.C.E.No 1 <br /> 'I R.S. or R.C.E. Name T'' _ <br /> . 'e Test Date/Time <br /> Test Location -� �, .��" <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Loc tion r �_ <br /> Owner ` Address ❑ PACKAGE PLANT <br /> ❑ SEPT ANK ❑ CESSPOOL El LEACHING FIELD ' i AGE PIT F <br /> ❑ TEMPORARY ❑ NEW REPAIR 13-OTHER r f <br /> ❑ PERMANENT �� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30,19- <br /> 7 e Construction -Disposal Site + <br /> Type e-„,---.. <br /> No. of Units IN "'Equipment:Storage/Cieaning•LocationI , <br /> I 6. ❑ PACKAGE TREATMENT PLANT For <br /> y 1, -June 30, 19 Where Certified <br /> t Operator Name <br /> Plant Location <br /> No. Units Served <br /> i Plant Capacity N <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. A* <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I s <br /> I 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 rules a regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> f <br /> 1 <br /> FOR DEPARTMENT USE NLY <br /> r;, <br /> f Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ nuary 1 &Received By January 31 July 1 Received By July 31 <br /> REMIT <br /> BILLING, ITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION TE DATE REMITTED _ AMOUNT <br /> If cz, <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Delivered <br /> Received by. Date <br /> Receipt No. w Permit o. Issuance Date Mailed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTO�,P•0 flox 200 '�S�TO�C�KT CA 95 1, <br />