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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 /> ENVIRONMENTAL HEALTH PERMIT S>wPTAGE <br /> LIQUID WASTE <br /> Applic is ttipr7by rude to carryon busi ss i he}'��Isdi 'onal area of th ry�gaq ocal Hea t ict r <br /> F Busi ame (DBA Ms <br /> t <br /> dress VV <br /> Z Ow er Address <br /> a <br /> Firm Partners, Addresses an e eabone N94ers <br /> a. Business Telephone No. i Emergency Telephone No. y ' <br /> Contractor Licence No. AXI <br /> �Applicants Name (Print) Title Date - <br /> Please check Applicable'C e ry(1-7) and FIII in the uired Information I <br /> 1. ❑ .PUMPER VEHICLE'PERMIT'REGISTRATION (FOR EACH VEHICLE) <br /> ft <br /> For J 1�I y 1 �Jun6-30,'-19__- Disposal Sites l <br /> Description(Make/Yr:,,Color•) A <br /> Serial No, CAL. License No. CAL. Liccnse Rercwal No. V i <br /> Capac-V +. �--'�-' - - Gal., Weights & Measures No. P, <br /> Equipmenttparking Address I ' <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 k � <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 ation Test Date/Time <br /> 4. SANITATION PER 1T <br /> Job Ad L J� <br /> e f <br /> Own Address <br /> ❑ PTIC TANK ❑ CESSPOOL 11LEACHING FIELD ❑ SEEPAGE PIT ❑ P KALE PLANT <br /> l!S PERMANENT ❑ TEMPORARY ❑ NEW REPAIR �-:Ar� <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'l, ,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 /> k 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 pules and re ions the Sa_n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE. ; ❑.EACH - _�-❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING' REMITTANCE AMOUNT DUE CHECKED <br /> - a DATE DATE REMITTED AMOUNT <br /> FEEq, <br /> LESS <br /> PRORATION cr <br /> PLUS <br /> k PENALTY <br /> 1 .....OTHER <br /> e OTHER ' ' <br /> gh <br /> Received by Date Receipt No. Permit No. Iss ante Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O..Box 2009 STOCKTggN,CA 95201 <br />