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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i APPLICATION <br /> ;a (For Non-Transferable, Revocable,and Suspendable) SI:PTAGt: <br /> ENVIRONMENTALMEALTH PERMIT <br /> LIQUID WASTE <br /> fI <br /> Applicati is hereby mad to carry siness in the' isdictional area of thin L cal th District <br /> r. rn Business Na (DBA) S� A7ddres c JW 'N44 <br /> i Owner Address fes+ 1/ <br /> 4 <br /> j Firm Partners, Addres es and Telep o Number <br /> N. Business Telephone No. ' Emergency Telephone No. <br /> Contractor Licence No. „ <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> I Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> i,. <br /> Capacity Gal: <br /> ,�Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i For July 1, June 30, 19 <br /> No. of Vehicles Stored - <br /> No. of Chemical Toilets Stored <br /> b' <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name I <br /> TestLoc n Test Date/Time <br /> 4. W SANITATION PER <br /> Job Addre oca_tion <br /> l,�DS �. Addres�S�EEPAGE�PIT <br /> 0wne.- 4 6 <br /> ❑ SE TIC TANK -❑�C,ESSPOOL a ACHING FIELD ❑ PACKAGE PLANT <br /> [!�► ❑ f MPORA iY- ❑ NEW. ', ❑ REPAIR ` Lt <br /> ERMA'NEN7 _ ,IT <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 /> ?� t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name r <br /> Plant Location v g f i - <br /> Plant Capacity No, Units Served ". <br /> 7. ❑ LAUNDRY For July 1, -June 30 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY/1,./,�(LEANING, Chemicals Used/Amount/Mo. <br /> l hereby certify that I have prep d this application a t the work,wlll 6e done in accordarlce`with San Joaquin County <br /> ordinances, state laws, and a nd re ulations of Jo ui L I ItLi�District.-.. <br /> APPLICANT'S SIGNATURE <br /> ' FOR DEPARTMENT USE-ONL-Y-$--�.-'-'r"�:'."`..r'-"'.'.`-' _.". - <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SIT£ ❑ EAG ❑ January 1 &Received By January 31 ❑ Juiy 1 &Received By July 31. <br /> REMIT <br /> r ,BILLING REMITTANCE � <br /> AM017N7 DUE CHECKED <br /> BASE - EXPLANATION-... -DATE DATE v�FIEMITTED i AMOUNT <br /> FEE <br /> LESS .£,.;wxw <br /> PRORATIONr _ J <br /> PLUS F r K !1 �� <br /> PENALTY <br /> r <br /> OTHER <br /> OTHER <br /> `Received by Date Receipt No. ,_„„- Permit No, Issuanc ate Mailed Delivered ' <br /> AP�PLICANT—RETURN ALL CLO.PIES So: ENVIRONMENTAL HEALTH.. <br /> 1601 E.HAZELTON <br /> AAVE.,P.O.Bo:20U9 STOCKTON,CA 95201 <br />