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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> I (For Non-Transferable, Revocable,and Suspendable) <br /> w F SI=PTP,GE <br /> ENVIRONMENTAL--.HEALTH PERMIT <br /> LIQUI11 WASTE <br /> Application +eriebbyy ma eeAo cra�rry�on b ess in the isdictional area oft Joaq o altJ1 D trict <br /> I Business Name (DBA) Add Add res <br /> ' z Owner Address <br /> k a <br /> M Firm Partners, Addresses and p one�NumbC <br /> a Business Telephone No. Emergency Telephone No. <br /> Q <br /> Contractor Licence No. I O <br /> Applicants Name (P Ism l Title <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�I' Disposal Sites <br /> �. Description(Make/Yr., Color) I <br /> Serial No, IMi CAL. License No. CAL. License Renewal No. <br /> r <br /> Capacity ISI Gal., Weights & Measures No. <br /> P Y <br /> Equipment Parking Address !II <br /> 2. ❑ PUMPER YARD q. wr <br /> For July 1, June 30, 19I <br /> No. of Vehicles Stored 1I <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 II TestDate/Time <br /> _ <br /> 4. © SANITATION PERMIT I�I� ` j, �, <br /> Job Add tion " <br /> Owner b" Address - <br /> ❑ SEP C TANK 1:1 CESSPOOL EACHING FIELD':_---attPA•GE RIT ❑-PACKAGE-PLANT ;. <br /> 1=RMANENT ❑ TEMPORARY C,>9 WEW_ -O kEPAIA ❑ OTHER 4ti <br /> 5. 13 CHEMICAL TOILETS For July 1, -June 30, 19 :. `� �, ,�' <br /> Type Construction -Disposal Site <br /> Units eStorage/✓eaningNo. of FLon{s) <br /> 6. ❑ ^PACKAGE TREATMENT.IPLANT For July 1, -June 30, 19 <br /> III <br /> Operator-Name I Where Certified <br /> Plant Location r I11�rgI <br /> Plant CapacityNo. Units Ser-yed ' <br /> 7. ❑ LAUNDRY'' For July 1, June 30, 19 - <br /> SIZE: - ❑ Lessjlhan 1,000 Sq. Ft., ❑ More Than 1,000 Sq:=Ft ,'y - <br /> ❑ DRY CLEANING;;Chemicals E sed/Amount/Mo. <br /> j I hereby certify that ) have re red this application and that the work will be done in accordance wtth`5an Joaquin County s <br /> ordinances, state laws, a s and r gulation Sa J a ealth District. <br /> APPLICANT'S SiGNATPF <br /> II <br /> t <br /> FOR DEPARTMENT'U$E"ONLY`"."-='-- <br /> `m�."`"`"""'..�"'�"_"""'r" <br /> Fee 1s Due: ❑ ANNUA LY I r� ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> i ,.¢'BASE" EXPLANATION GATE DATE REMITTED AMOUNT DUE, CHECKED <br /> AMOUNT <br /> C <br /> l FEE I` <br /> LESS v`t IIII <br /> PRORATION \g I+ <br /> PLUS e l <br /> PENALTY <br /> ` OTHER <br /> OTHER <br /> . <br /> Received by Dale Receipt No. Permit No I uance ate Mailed Delivered <br /> } APPLI ANT_RETURN ALL COPIES TO; ENVIRONMENTAL HEALTH PERMIT/SERVICES 16U1 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />