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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> 51=PTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl icatiD ' hereby ma a to carry on business in the jurisdictional area of tu San aquin Logal H It istricj <br /> Business Name (DBA) Address e D <br /> z Owner Address �r <br /> Firm Partners, Addresses and Telephone Numbers _. . <br /> aBusiness Telephone,No. n-� - Emergency Telephone No. <br /> -J Contractor Licence NO. ' <br /> L Applicants Name(Print) + n 'Title S �. Data <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 <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' _ .t <br /> R.S-or R.C.E. Name R.S. or R.C,E No. <br /> Test ocation Test Date/Time <br /> 4. i SANITATION PER IT C <br /> Job Addr /Location _ <br /> Owner Address s <br /> ❑ SEPTIC TANK' ❑ CESSPOOL LEACHING FIELD �REPA <br /> AGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW s IRI] OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 +a r1 ~ <br /> Type Construction #.. Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) , <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, June 36, 119 <br /> Operator Name ` `` t Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> f d <br /> 4 <br /> -!�! . • I is. � r - r # <br /> I-'hereby certify that I'Have prepared this application a d that the work will be done in accordance with San Joaquin County <br /> ordinances, state-.-laws,,a rules and 16dulab the San Joaquin Local Health District. & i <br /> APPLICANT'S SIGNATURE X <br /> •���e ,� 4.4 - � i .�...,. j� l ..�i,,, ,. ....per .f - f - ., <br /> FOR DEPARTMENT USE ONLY -- <br /> � .k.,IL S <br /> Fee Is Due: 11 ANNUALLY ❑ PER.UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 [1 July 1 &Received Cy July 31 <br /> REMIT i <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED - <br /> DATE DATE REMITTED AMO NT <br /> FEE <br /> LESS <br /> PRORATION' <br /> PLUS <br /> PENALTY <br /> OTHER . <br /> OTHER <br /> Received by Date Receipt No. - Permit No, Issuance D e Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boii 2009 STOCKTON,CA 95201 <br />