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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S�PTAGE <br /> (00 2-1 2.J. A-E V Cul 1¢-4. LIQUIU WASTE 12-c(— 190 <br /> Ap'plicati i her by ma car n busi ss in the jurisdictional area of the San Jo <br /> ac UUin L I He tr' <br /> NBusiness N.Qmp. (DBA) Address �DJ <br /> z Owner Address Ze IF <br /> a <br /> J Firm Partners, Addresses and Tel ne ur er <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> ' r Date <br /> �Applicants Name (Print) Title <br /> Please check Applicable Category (1-7) and Fill in the equired 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. CAL. Licc"se Renewal No. <br /> Capacity Gal.,Weights & Measures No. } <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> 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.C.E. No. <br /> Test Location Test Date/Time <br /> 4. XSANITATION PE IT <br /> Job Addres Lo ation <br /> Owner �r ¢ Address <br /> ;SEPT TANK C1 CESSPOOL LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE ANT <br /> PERMANENT ❑ TEMPORARY P7NEW ❑ REPAIR ❑ 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 /> Plant Location <br /> Plant Capacity . No. Units Served <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 /> I hereby certify that I have repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws d s and re ula ons of the Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X (] <br /> • t,��f� <br /> ci <br /> C <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE `�t� ° �_'3 a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit No. Issuance D to Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX20QIL STOCKTON,CA 95201 <br />