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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �(0APPLICATION <br /> S z, (For Non-Transferable, Revocable,and Suspendable) I i '* "'1 <br /> ENVIRONMENTAL HEALTH PERMIT } TAGS <br /> / }� <br /> LIQUID WASTE '- <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) 6PAI-:IT� C—;r7O-J Address <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. S 3 9-7 Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) F'4_6y2 Title � � Date "s' SZ <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 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Lic:.nse 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 Stared <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. J4 SANITATION PERMIT <br /> Job Address/Location 4 AJ7 <br /> Owner !: E5 V.1 LL L S Address ri•• <br /> SEPTIC TANK ❑ CESSPOOL 2T LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY P9 NEW ❑ 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. d <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application andthat thework.Wt -e—done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations f the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X 11 AQ <br /> � O <br /> 7 <br /> FOR DEPARTMENT USWIX <br /> Y <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT 11 PER SITE ❑ EACH 1:1 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMIT CE $ REMIT <br /> BASE EXPLANATION DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS ` <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance 96te Vailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 [� <br />