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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 &FPTAGE i <br /> f1 LIQUID WASTE 4 <br /> Applicationi reby mpde to c rry on sine area of the SaJoaquin Local He <br /> in th 'ur' dii nal alt lstnct <br /> FB N (DBA) `!! ddress �" 76 `T �� I <br /> zOwner Address <br /> J Firm Partners, Addresses an Telephone Numbers <br /> aBusiness Telephone Emergency Telephone No. <br /> �Contractor Licence No. z2 <br /> - � <br /> L Applicants Name.(Pri_nt) = F' f`-e Title Date <br /> Please check Applicable Catego (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) -1 <br /> Serial No. CAL. License No. CAL. Lictnse Renewal No. <br /> Capacity - Gal.,Weights-& Measures"No:w -- - - - ----- `— <br /> *Equipment Parking Address 4 <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./orR :E�. Name R.S. or R.C.E. No.Tesion Test Date/Time <br /> 4. ITATION PERMIT <br /> 4 Job Addre /L cation <br /> ,O.,w�r dd s— � El PACKAGE PLANT O <br /> t�"SEPTIC TANK © CESSPOOL ACHING FIELD C1 SEEPAGE PIT <br /> i ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> s <br />'4 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 Plant Location <br /> Plant Capacity "' No. Units Served" <br />` 7. ❑ LAUNDRY For July 1, - June 30, 19 <br /> II SIZE: ❑ Less Than 1,000 Sq. Ft.1 ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 and reg do s of the San Joaquin Local Health District. <br /> Y <br /> APPLICANT'S SIGNATURE <br /> e <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS ` <br /> PRORATION _ <br /> PLUS ; <br /> PENALTY <br /> OTHER <br /> a <br /> OTHERi n <br /> E Received by Date Receipt No. Permit No. 'Is uance Mte Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />