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- Applications Wil!BePessed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SE PTAGE <br /> ,•:: . LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of thei�Joaquin Local Health District <br /> rn Business Name (DBA) �i r®GL � Address `G /Yl% <br /> aOwner Address t i <br /> k Firm Partners, Addresses and Telephone.Numbers p� <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ I <br /> L Applicants Name (Print) �% �4Q Title 4&4,,,AA07re- Date—,.7- <br /> Please check Applicable Category (1-7) and Fill in the Required Information h <br /> 1, 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)' <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> r. <br /> Serial No, CAL. License No. CAL. License:Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address ti <br /> 2. ❑ PUMPER YARD ' <br /> For July 1, June 30, 19 g, <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored _terms <br /> 3. ❑ PERCOLATION TEST ¢ ' <br /> R.S. or R.C.E. Name 'k R.S. or R.C.E. No. <br /> E � <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner %iJG- <br /> Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD' ❑ SEEPAGE PIT ❑ PACKAGE RLA?W <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> t <br /> No. of Un s '�.: Equipment Storage/Cleaning Location(s) '# <br /> 6. ❑,PIA'C"G -TREATUENT'PLANT For-July-,une-30,-b9 <br /> Operator.Name Where Certified <br /> Plant Location -- - <br /> Plant Capacity zz Ido.-Units Served a f <br /> 7. 0,1LAUNDRY For July 1, -June 3019 R _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ I]RY CLEANING, Chemicals Used/Amount/Mo. <br /> r I;hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> + ordinances;.state laws, and rules and r gulati nsiof_the_Sarl.Joaquin Local Health District. ; I <br /> t-Y <br /> APPL�ICANT'SaSIGNATURE X <br />. ot <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due::9—NNUALLY PER UNIT ElPER SITE ❑'EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> - 11�1 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED c9� AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER \ 1 �I� +f <br /> OTHER <br /> N' <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 AVE.,P.O.Box 2009 STOCKTON,CA,95201 <br />