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Applications Will Be Processed When Submitted Properly Completed Be sure 10al9n I"r- <br /> APPLICATION <br /> zAPPLICATION <br /> j <br /> ' (For Non-Transterabie, Revocable,and 5uspendable) pTAC,F <br /> T� ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appiicati is herebyp�ade to carry olj b ess in the'ur' ictional area of th all Jo uio cal Ith Distri 1 <br /> 1✓/Iyra q CG Address <br /> Business Name DBA)y (� <br /> Address <br /> z Owner <br /> a <br /> J.Firm Partners, Addresses and T eph ne Numbers Emergency Telephone No. <br /> CL Business Telephone No. <br /> a _ <br /> Contractor Licence No. > Date I <br /> S Title <br /> �Applicants Name (Print) "" <br /> Please check Applicable Category (1-7) and Fill In the Required Information <br /> E 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 <br /> Disposal Sites {�y <br /> w <br /> Description(Make/Yn, Color) CAL. Licc„se Renewal No. <br /> Serial No. CAL. license 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 Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> ( R.S. or R.C.E. Name <br /> 's Tesk L cation Test Date/Time <br /> 1 41: $C dITATION PERMIT `w <br /> Job Addres ocation <br /> Owner Address ❑ PACKAGE LAN <br /> OTHER <br /> ❑ SEPTIC TANK � ❑ CESSPOOL , �LEAGHING FFIELDSEEPAGE PIT /��( JL�� �r <br /> I PERMANENT 13TEMPORARY" 13 NEW <br /> REPAIR �(/ G <br /> i <br /> S. El CHEMICAL TOILETS'-,For July 1, -June 30, 19 �+ <br /> I Type Construction r- Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq.-Ftr <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> d I <br /> I hereby certify that I have prepared this application and that, <br /> the work will be done in accordance with San.Joaquin oun y <br /> ordinances, state laws, and rules ulati s t San Joaquin Local Health District.— <br /> tt APPLICANT'S SIGNATURE X <br /> F FOR DEPARTMENT USE ONLY _ <br /> ,i d By J <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT El PER SITE ❑ EACH ❑-January 1 &Received By January 31 •❑ July 1 &Receiv REMITuIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION .. DATE DATE REMITTED AMOUNT <br /> f <br /> FEE <br /> r LESS <br /> ft PRORATION <br /> PLUS <br /> F PENALTY <br /> f � <br /> OTHER <br /> OTHER k <br /> Date Receipt No. Pe'mit.No. sua a Date ailed Delivered <br /> Reieived by r - 1601 E.HAZELTON AVE.,P.O.Box 21109 STOCKTOI,CA 95202,. <br /> L—.� APPLICANT—RETURN ALL COPIES TO:'. ENVIRONMENTAL HEALTH PERMIT/SERVICES - - <br />