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Applications Will Be Processed When Submitted Property Completed. Be SureTo SignTheAppucau n <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SVPTAGE <br /> w ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE i <br /> Application is here�]y made to carry on business in the jurisdictional area of the San 1%.Local <br /> .Local Health District <br /> ,F Business Name (DBA) A 41 /uGG��12 Address � i <br /> aOwner ./-. /7i�iGL'� Address <br /> j Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. � Emergency Telephone No,.. <br /> Contractor Licence No. <br /> Applicants Name (Print) J�CiGG Title ��'-��-Z/3�� • Date � <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4 r <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) _ <br /> • <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity,- -- ---=Gal., Weights &-Measures-No. <br /> Equipment Parking Address , <br /> 2. ❑ PUMPER YARD <br /> For July i, June 30, 19 4•1 <br /> .� ,_,, ; <br /> i. <br /> No. of Vehicles Stored ` <br /> No. of Cliemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. I <br /> Test Location Test Date/Time ' <br /> li 1 <br /> 4. ❑ SANITATION PERMIT J �Y. t' <br /> Job Address/Location 0 T <br /> t \ 1 <br /> O�w n� - <br /> O SEPTIGTANK ❑ CESSPOOL LEAGHIidG FIELD ❑-SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT 13TEMPORARY ❑ NEW !""❑`REPAIR°' ❑ OTHER' 7 1� <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r' ; <br /> Type Construction Disposal^Sete E �\ <br /> f'4 �I - �:ao���y�•+�r".u��r._^- -.—. -N �.x+Y'�+'y�"'"+�. � mr <br /> No" of Units = Equipment Storage/ lganing Location <br /> 6. ❑ PACK4GE TREATMENT-PLANT—For July-1T June"30 99 N`r " <br /> Operator.Name := - where Certified <br /> k A ¢ <br /> Plant Location r <br /> Plant Capacity- '^ No. Units Served <br /> -7. 11LAIINDRY� For July 1, -June 30, 19 r•-.�—s i " <br /> SIZE: El Less Than 1,000 Sq. Ft� ❑TMore,Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo: <br /> I hereby certify that I have prepared this application and that the work will.berdon,lin,accorlance with San Joaquin County <br /> ordinances, state laws, and rules and re tion the 5 Joaquin Local Health District <br /> APPLICANT'S S G <br /> FOR DEPARTMENT USE'ONLY- -- c <br /> i f s <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January1 &Received By Jarrua'ry 31�i ❑':J�y 1 &Received By July 31 <br /> _ REMIT <br /> ' BASE EXPLANATION BILLING �' REMITTANCES' -+r-- ' y AMOUNTVUE CHECKED <br /> DATE �. DATE REMITTED tAMC'UNT <br /> r i <br /> LESS l ! <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> � s <br /> OTHERS <br /> . ? ; �..._�,�----��--�-�~�'-°-•,•1�o�- �-110 -�1 ,. <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed Delivered <br /> APPLICANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES" 1601 E.HAZELTON AYE.,P.D.Box 2009 STOCK TON,CA 95201 r' <br />