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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> --,NNEMP- APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> . ; Se�raGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati s hereby rjade to carry on business in the urisdictional area of the San Joaquin Local Health District O <br /> w Business Name (DBA) s /d /«f c57 .StF;eyle Address-/ S, AO L 1,;zw' ) <br /> a Owner—_m-_I 16) I� G Address/7l1 S . e9 AO 4-4 14e"et' <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No.y` S,, R�wel b Emergency Telephone No. <br /> Contractor Licence No. 3 t- � - <br /> L Applicants Name (Print) t// 4 /���X li/ Title L TDate /- 3-9 p <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. License Renewal No. <br /> Capacity Gal.;Weights &Measures No. <br /> Equipment Parking Address 777 <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time - <br /> 4. SANITATION PERMIT S f #.CACAO f <br /> Job Address/LocationJ;Z <br /> Owner Address a S � '� <br /> ❑ SEPTIC TANK ❑ CESSPOOL KLEACHING FIELD LXSEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ 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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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, ru and regulations of the San 4oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT Xr PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY c- <br /> OTHER <br /> OTHER <br /> 037(o( ! �d <br /> Received by Date Receipt No. Permit No. Isstiance Date Mailed Delivgfed <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E,HAZELTON AVE.,P.O.Box 2009 STO A 95201 <br />