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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> V' APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) WVAGI <br /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Name (DBA) Addressp-a 114co _ 5-rr_Q CSS7C0 1 <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 0. Business[Telephone No. . '7t[�67 ' o�� _ Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) �.7r1"A-Tl Li=y S. !St M�„�, ._. Title ESTI T.!A" 90FK Date 44-17 I <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 /> Equipmetlt Pdrking Address <br /> 2. ❑ PUMPER YARD <br /> For July.1, June 30, 19 <br /> No. of Vehicles Stored _ <br /> No. of Chemical Toilets Stored 'ti <br /> 3. ❑ PERCOLATION TEST' <br /> R.S. or NIP. Name 3 _ R.S.or R.C.E. No.- <br /> Test Loci `; Test Date/Time <br /> I(. <br /> 4. l NITATION PERMIT, <br /> Job Address/Location I; aS, 5144>0L AVE-, <br /> Owner .'U 4sU.JIVIs6ts) %Sr• Address <br /> ❑ SEPT[C TANK$,-.❑ CESSPOOL BLEACHING FIELD} —'SEEPAGE PIT ❑t�,PACKAGE PLANT <br /> 01PERMANENT ❑ 'TEMPORARY 11 NEW RbKO <br /> EPAIR THER <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 r Where Certified R <br /> Plant Location I f 7 <br /> 77 <br /> Plant Capacity ( f A 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 h e prepared this applicaltj'py and that the work will be done in accordance with San Joaquin County <br /> ordinances, state law ulatic the Sagtrl Local Health District. <br /> APPLICANT'S SIGNATURE <br /> F <br /> FOR DEPARTMENT USE ONLY _ <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31'� El July 1 &Received By July 31 <br /> ' REMIT <br /> $ <br /> BASE EXPLANATION BILLING REMITTANCE DATE DATE REMITTED MOUNT DUE CHECKED <br /> /�' AMOUNT <br /> FEE <br /> LESS 1 <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER t f <br /> OTHER <br /> h – i. <br /> Received by Date Receipt No. Permit No. F Issuafice Date Pileili Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. 2009 STOCKTON,CA 95201 <br />