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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 /> . <br /> ENVIRONMENTAL HEALTH PERMIT SE!PTAQE' .. <br /> LIQUID WASTE <br /> Applicati is h re made to c ry on t�siness in th jurisdictional area of than aquin Local Health Istrlct <br /> OF Business Name (DBA) <br /> • �� s Ute✓. Address <br /> aOwner Address <br /> Firm Partners, Addresses and Te/�ephone umbers <br /> a. Business Telephone No. to `Q�a Emergency Telephone No, <br /> Contractor Licence No. — _. <br /> Applicants Name(Print, ; 6- Title Date Za �(1 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 ' <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L cation Test Date/Time <br /> 4. L7 SANITATION P MIT, <br /> Job Add s/Lo atio S� <br /> Owner Address " <br /> 11 SEEPTIC TANK ❑ CESSPOOL �LEACHi G FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT E] TEMPORARY ❑ NEW REPAIR ❑ OTHER <br /> 5. E] 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 a <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, a d rules and egulati 7f the a Joaquin Local Health District. <br /> I <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ja PER SITE ❑ EACH 1 January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> KILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECK <br /> AMOUNT <br /> FEE �/ a <br /> LESS <br /> PRORATION <br /> PLUS p <br /> PENALTY <br /> OTHER <br /> OTHER ` <br /> Received by Date Receipt No. Permit No issuance Date Mailed ;el,,, red <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ST KTON,CA 95201 <br />