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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> " .s APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SE PTAGE s <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _'?� LIQUID WASTE <br /> ApplicationxPreby made o cart Son siness in the jurisdictional area of the San JoaquinAo I Health District ,S <br /> rn Business Name (DBA)�,� Address <br /> z Owner GAS P,¢, is Address lF <br /> a <br /> kJ,Firm Partners, Addresses and Telep one Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. oe <br /> LApplicants Name (Print) ' �'�`���`�. Title Date <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. Liccr:se Renewal No. <br /> Capacity_ Gai.,--Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> k 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. ❑ SANITATION PERMIT G <br /> Job Address/Location _ <br /> Owner ter I Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL I K LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT 1 <br /> 11 PERMANENT, [] TEMPORARY 11NEW ❑ REPAIR -1 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. a .y�+ 'd% <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have ared this appl' do nd that t wo ill be done ordanw- with San Jdtiquin County <br /> ordinances, state laws, a ' s nd regulati n e San Jo in Local Hea District. <br /> APPLICANT'S SIGNATURE X f <br /> I <br /> FOR DEPARTMEN USE ONLY <br /> Fee IS Due: 11 ANNUALLY PER UNIT ❑ PER SITE 1:1 EACH, ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> _ - AMOUNT <br /> I FEE p-4-7 75 15-- <br /> LESS 5-LESS <br /> r PRORATION <br /> { Ptus <br /> PENALTY <br /> I <br /> OTHER - <br /> OTHER <br /> /G 41 y a <br /> Received by Date Receipt No. Permit No._ Assu rice Dae Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201 :f <br />