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Applications Will Be Processed When Submitted Properly Completed.Be Sure To_Sign The Application. <br /> I <br /> yet to APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> I` fit ENVIRONMENTAL HEALTH PERMIT SEPiAGE <br /> LIQUID WASTE I <br /> Applicati �s'Iher�eb'y` ode to ca on busine n the jurisdictional area of the San Joaquin Loc ealth istrict <br /> F Btksiness Name (DBA)� �� Olfl ..f b _ Address �4 �� S <br /> a Owner Address : <br /> FiYm Partners, Addresses an le hone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Priv l Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1.1� ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 - ,. Disposal Sites <br /> Description(Make/Yr., Color) rte° <br /> Se,riai No. ` '" 'CA Ar-License No. CAL. License Renewal No. r <br /> Capacity Gal.,Weights & Measures No.`#► <br /> Equipment Parking Address <br /> f <br /> 2.'�`❑ PUMPER YARD � - <br /> For July 1. June 30, 19 <br /> No. of Vehicles Stored <br /> k : <br /> No: of Chemical Toilets Stored <br /> 3.1� ❑ PERCOLATION TESTS L '= <br /> R.S. or R.C.E. Name .- R.S. or R.C.E. No. <br /> Test,_Locat' Test Date/Time b <br /> 4. Cl SANITATION PERMI <br /> Job Addr s/Location - �� # -- <br /> Owns Address ' s ' <br /> SEPTIC TANK ❑ CESSPOOL �EACHING FIELD B' `j=pAGE PIT ❑ PACKAGE PLANT y <br /> ®P RMANENT ❑ TEMPORARY 11_t4EW,_. aEp� ❑ OTHER <br /> 5.1� ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ;¢ f <br /> Type Construction t Disposal Site <br /> No.-of`-Un lt` + � Equipment Storage%Glean`g Lwoeation( '� <br /> s) <br /> U <br /> 6 � 'PACKAGE TREATMENT PLANT For July 1, -'June-30,19 <br /> Operator`Name`' `i �- Where Certified r <br /> Pla -t. -w" - <br /> nt Location ':' € .,, i <br /> Plant Capacity No. Units Served r <br /> 7.Ip❑ LAUNDRY 'For July 1,`-June 30, 19a <br /> SIZE: 13Less Than 1,000 5q, Ft., ©More Than 1,000 Sq.-Ft. �; ) <br /> ❑ DRY CLEANING, Chemicals Used/Amoont/Mo ,+- <br /> . ., ' yam' � . <br /> I hereby certify that I:have pre d this-application', a wor will bd done in-accordance with 5ari'Joaquin County <br /> ordinances, state laws, and'r and re ulation J o al He istrict'~ /� 4 <br /> 'tee_ <br /> Adi <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY f t <br /> f <br /> [[ Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received, � nuary 31 ❑ Juty 1 &Received By Jufy 31 <br /> - HIDING ,4, REMITTANCE a REMIT <br /> _EXPLANATION s f �VT <br /> t AMOUNT DUE CHECKED13DATF— GATEAMOUNT a <br /> FEELESS <br /> f�7 Y �» .. �'} 4: �t , y�: y _ • h 4 , <br /> PRORATION ' r <br /> PLUS »LLs 4 <br /> i� PENALTY - <br /> _ <br /> S <br /> i OTHER <br /> r '1 <br /> OTHER —Y tM� <br /> !� <br /> Received by Date Receipt No. Permit N( Issuadce Dae Mailed Delivered ; <br /> .I y APPLfCANT—RETURN ALL COPIES TO: � ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HRZELTON AV -, .0.Box 2009'. STOCKTQN,CA 95291 - <br />