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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 SEPT„GE <br /> 1 LIQUID WASTE <br /> Application is hereby made to'car�on busines n the jurisdictional area of the 5a quirt Lo Heath District+ �'�" <br /> F Business Name DBA) /fps l z.__v� 7 � �"�� Address + L �. .* 'Ce 01 A- y --� <br /> 4Owner— • L� (r Address 1 f /�a '�.� '� A471'� - <br /> -— �� <br /> J Firm Partners, Addresses and Teleph ne Numbers <br /> IL Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) ✓ Title : DateIf j <br /> j 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:;nza Renewal No. <br /> Capacity ' <br /> Equipment Parking Address I <br /> t <br /> 2. ❑ PUMPER YARD 14Z', <br /> For July 1, June 301, 19 <br /> r No.1oi Vehicles Stored <br /> No-',,of Chemical Toilets Stored s <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. ❑ SANITATION;PERNUI W <br /> [: <br /> JobiAddress/ ation x i g Qc <br /> Owner Address 4~ 0 <br /> EPTIC TANK CESSPOOL LEACHING FIELD ❑ SEFPAC E PIT �`❑ PACKAGE PLANT 't <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR THER <br /> ICA <br /> 5. P CHEMICAL TOILETS For July`I;-June 30 19 �F ` <br /> Type Construction _ Disposal Site,---- <br /> Na:of Units ° r— - Equipment Storage/Cleaning Location(s)'' <br /> 'X. vt <br /> _ fi. 0 PACKi4'�E TRE�AT.MEN7 PLANT�For July 1, -June 30, 19'-'" <br /> ' s <br /> Operator Name �'� Y r _ ^ ��� WhereCeitited ` <br /> Plant Location <br /> Plallt Capacity_ No UnitsServed -''' <br /> 7. ❑ LAUNDRY For July 1, -June 30,.19 <br /> SIZE: ❑ Less Than 1,000 Sq"Ft., }❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.-- <br /> I hereby certify that I have prepared t appli ation a that the work will be done in accordance with San Joaquin County <br /> iordinances, state laws, and rul s an g I soft Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X r �J <br /> FOR DEPARTMENT USE ONLY I. <br /> i <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July"I &Received By Jury 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> - BASE EXPLANATION AMOUNT DQE y CHECKED <br /> - DATE DATE REMITTED AMOUNT. <br /> FEE �1� i <br /> LESS <br /> PRORATION s` <br /> 3 PLUS <br /> PENALTY '; <br /> OTHER I I <br /> OTHER <br /> Received by 'Date Receipt No. Permit No. - - Iss ante Date Mailed D red <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL-TON AVE.,P.D.Box 2009 STI16CKTON,CA 201 <br />