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D Applications Will`Be Processed When Submitted Properly Completed:Be Sure To Sign The Application, ' <br /> APPLICATION � 'e/.. ami <br /> 71 (For Non-Transferable, Revocable, and Suspendable) Vo <br /> ENVIRONMENTAL HEALTH PERMIT SEFtT�iGE <br /> i <br /> r LIQUID WASTE <br /> M Applicatio i here y mad o on bu ess' t jurisdictional area of the San Joaq Local Health istrict <br /> y Busine - AZ17A <br /> 11iss a (DBA) Address <br /> aOwn 4 - - Address l " r <br />—2 Firm Partners, Addresses and Telephone Numbers � � <br /> K Business Telephone No.. Emergency Telephone No. - r+ <br /> Contractor Licence No. O 57 <br /> a Appliicants Name (Print) t' �f Title <br /> L ;p Date 7-' <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑j,PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For J it#ly 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. , <br /> Equipment Parking Address l <br /> 2. C]I PUMPER YARD <br /> For Jul ly 1, June 30, 19 <br /> No. of Vehicles Stored <br /> I1' <br /> No. ofChemicalToilets Stored <br /> 3. ❑IJIPERCOLATION TEST <br /> R.S. o11r R.C.E. Name R.S. or R.C.E. No. <br /> Test i1ocation Test Date/Time <br /> 4, SANITATION PERMIT <br /> Job Address/Location r? / <br /> Owner Address Ste-- <br /> a SEPTfC TANK ❑ CESSPOOL 8-LEACHING FIELD WSEEPAGE PIT ❑ PACKAGE PLANT <br /> 911E6ANENT ❑ TEMPORARY a-litEW ❑ REPAIR ❑ OTHER <br /> S. 01!CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site �I <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. ❑I LAUNDRY For July 1, -June 30, 19 <br /> SIZE:h ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> II I hereby certify that I have prepared this applicati and that the work will be done in accordant with San Joaquin County <br /> II' ordinances, state laws, and snd regulations th a Joaquin Local Health District. fe E, <br /> APPLICANT'S SIGNATURE X ' <br /> p, FOR DEPARTMENT USE ONLY <br /> I s <br /> ee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By my 31 <br /> BILLING REMITTANCE $ R <br /> RASE EXPLANATION AMOUNT DUE CH KE?"\ <br /> RATE DATE REMITTED - O 1 <br /> !FEEL <br /> r'LESS <br /> ��FRORATION -. <br /> Illy <br /> PLUS <br /> ,PENALTY <br /> ( <br /> OTHER <br /> ''F I <br /> BOTHER <br /> ecelved by ,moi -' Date - Receipt No. Permit No, ssuanc Date Mailed Delivered - <br /> APPLICANT'—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> 40 _ <br />