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,7plications.Will $e Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> i 'J � `3, APPLICATION <br /> _ (For Non-Transferable, Revocable, and Suspendable) . <br /> 1 �} ENVIRONMENTAL HEALTH PERMIT " " 5 P GE <br /> r [z_ LIQUID WASTE A :) <br /> Application ' h eb de t rry on busi ss the jurisdictional area ofthe San Joa uin <br /> q L cal t ric ( ,� <br /> Business Name (DBA) �`� <br /> Address <br /> 4 Owner Address <br /> J Firm Partne s, Addresses and Telephone Num rs <br /> IL <br /> Business Telephone No. Emergency Telephone No. *----�— <br /> Contractor Licence No. <br /> L Applicants Name (Print) ' <br /> Title Date i <br /> Please check Applicable Category (1-7)and Fill in the Required nformation �' f <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 7 <br /> For July 1, June 30, 19 Disposal Sites r <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 Location Test Date/Time <br /> 4 <br /> 4. A SANITATION PERMIT <br /> Job Addres Locatio <br /> ,,,0wner Addres <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PAC GE PLANT .+ <br /> PERMANENT ❑ TEMPORARY NEW REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site V I <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. 1:1 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 w <br /> Operator Name' '' r Where Certified I <br /> Plant Location , <br /> Plant Capacity.. No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 � f <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, an rul nd guI do the San Joaquin Loc Health District. <br /> 1 <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY � ,y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 it <br /> BASE EXPLANATION BILLING REMITTANCE. $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE � '� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss a e Date Mailed D ivere <br /> APPLICANT—RETqq RNA L'COPIES TO: ENVIRONMENTAL HEp`,L P IT/SERVICES 1601 E.HAZELTON AVE.,P.O.Sox 2009 STOCKTON.CA 11111 <br />