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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> i 70 (For Non-Transferable, Revocable,and Suspendable) CANAJWTAGE <br /> E ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application} reby made ry o7nusine in the jurisdictional area of the San Joaquin Local HeapDistrict / <br /> yBusiness Name (D )���! 4""' Address <br /> z Owner �- Address <br /> a <br /> Firm Partners, A dresses and Telephone Numbers ,- l <br /> (� <br /> 4 'r I- / Emergency Telephone No. <br /> aBusiness Telephone No. —t <br /> �Contractor Licence No. or / <br /> a �G-f GGA l Title Date <br /> L Applicants Name (Print) <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 /> CAL. License No. CAL. LPccnse Renewal No. <br /> Serial No. <br /> Capacity Gat., 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 <br /> R.S.or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Locn <br /> 4. SANITATION PERMIT t� _ - <br /> Job Address/L cation O U C <br /> e L L/' � w'L�'C�EACHING <br /> Address <br /> Owne� <br /> 11 PACKAGE PLANT �^ <br /> L4l�SEPTIC TANK ❑ CESSPOOL ELD EEPAGE PIT ❑ OTHER v <br /> 11 PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR 0- <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 /> Where Certified <br /> Operator Name <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, and rul s a e lations of the San Joaquin ocal,o4alt istrict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> ^ / DATE DATE REMITTED AMOUNT <br /> FEE 1{� liU <br /> 45 <br /> LESS <br /> PRORATION y <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> OSS`7R <br /> Received by Date Receipt No. Permit No. ssuance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 1 STOCKCA 5201 <br /> �N <br /> y�z 9 <br />