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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) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> I , <br /> LIQUID WASTE 0 <br /> Applicati is hereby ade to c rry on business in the jurisdictional area of the San Joaquin Lo I Health istrict �► <br /> ,Business Nam DB ) Address `. <br /> z OwnerAddress <br /> a ,l. <br /> J 4w�_5 <br /> Firm Partners, AddressesAnd Tlelephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in,th 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 /> ,i <br /> Serial No. CAL. License No. _ CAL. Licrznse Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. 1:1 PUMPER YARD <br /> For July 1, June 30, 19 <br /> 'No of of Vehicles Stored <br /> 'No. of Chemical Toilets Stored <br /> 3. 11 PERCOLATION TEST <br /> 'IR.S. or R.C.E. No.or R.C.E. Name a <br /> II Iest Location Test Date/Time I <br /> .4. ❑ SANITATION PERMIT'16 <br /> f <br /> ob Address/Location <br /> :1,O.�w�ner ' Address <br /> l SEPTIC T NK C1CESSPOOL M LEACHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> I❑ 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 I <br /> j <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 rules and regulation 9 the San Jo quin Local Health District. # <br /> APPLICANT'S SIGNATURE X <br /> I <br /> FOR DEPARTMENT`US Oar <br /> Fee Is Due: ❑ ANNUALLY- ❑ PER UNIT ( PER SITE ❑ EACH ❑ a ua &Received By January 31 ❑ July 1 &Received By July 31 <br /> _ - REMIT <br /> BASE EXPLANATION BILLING REMIT CE $ -AMOUNT DUE CHECKED <br /> DATE TE REMITTED AMOUNT <br /> FEE Orsi � <br /> LESS <br /> PRORATION A -. <br /> PLUS r <br /> PENALTY <br /> OTHER <br /> t <br /> OTHER <br /> Received by Date Receipt No. Permit No I suance Date Mailed ellver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,PA,Box 2009 5 C 95201 <br />