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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. I <br /> APPLICATION <br /> (For Non-Transferable;Revocable;and Suspendable) SERTAGE <br /> ENVIRONMENTAL HEALTH_ PERMIT <br /> LIQUID WASTE <br /> Applic . n is hereby ade to carryon bu iness in he jurisdictional area of the S Joa ui. Local Health District/ <br /> yti3usineame (DBA _1 Address— <br /> z Owne Address h <br /> Firm Partners, Addresses and Telephone Numbers <br /> 71 <br /> aBusiness Telephone No. Emergency Telephone.No. <br /> 1 Contractor Licence No. <br /> Applicants Name(Print) Title Date. <br /> _.Aeasefcheck Applicable C' gory (1-7)and Fill in a Required Intormaiion <br /> 1. .CI ;PUMPER`VEHIGL'E`PERMIT REGISTRATION (FOR EACH VEHICLE) ' <br /> For July 1, June 30,'19' Disposal Sites <br /> u, —�; � i <br /> f,€Ilescripti.orr(Njake/.Yr:;Coior)F {} <br /> CAL <br /> CAL. License No. . License Renewal No. I <br /> Serial No., - "'� - ' <br /> Capacity �� Gal.,Weights S Measures No. <br /> �Ir Equip ent,�artCing)Addr"ess11 <br /> i <br /> 2. ❑ PUMPER YARD i- ► <br /> For July 1, June 30, 19 <br /> ! <br /> No. of Vehicles Stored <br /> • 2 <br /> No. of Chemical Toilets Stored - <br /> r i <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 t <br /> 4. ❑ SANITATION PEIMp, <br /> Job Ad ss/Location (pp � , , tom . <br /> IFF, � Address <br /> PTIC TANK ❑ CESSP L C10EACHIN FIELD ❑ SEEPAGE PIT ❑.PAC GE PLANT c� <br /> 0- <br /> VPERMANENT ❑ TEMPORARY ❑ NEW REPAIR v <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. 11PACKAGETREATMENT PLANT For July 1, -June 30, 19 qw ; c"' <br /> Operator Name - I ' a { Where Certified <br /> ' T !• 1� " <br /> Plant LocationPlant Capacity 4No. Units Served7. ❑ LAUNDRY -F.or July 1., --June 30„19 SIZE: ❑ Less T4fian 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft.❑ DRY CLEANINGrChemicals Used/Amount/Mo. r1 Or"*ownerorlirensedaggWt' gnat�rec rt°ilnsfhgfotlowr»g '1Cprtl' r.ins ch'manner 2StQ I)arnr t �t ^ YhaSlritheP4rro'maRr.eofthevlTrkforw�IfChthisparmltisissued,Ishany <br /> cOni actrr`a lit:n ^ <br /> nnrr]c st.rr crn:r�; � atvi:lg; "i Certify that i;l til£ e,li"^129 ,;i si;? <br /> F::j l'-•"•,]a`{=1%r� a..,.��� iv Y _ ..::'... .,LJ-,(Jv ...,�:.:i3W3 <br /> of .i�I C e <br /> (' P Yd3l n fe,�v 1iCl 'tt permit is issued.i shat! <br /> " Ihereby-certify that I have prepared this application ai'-6-at the,wo bk will be done in accordance with San Joaquin County ) <br /> ordinances^state:lawsl, an ides-arid;re ulati s of the San Joaquin L�acal Health District. 4 <br /> APPLICANT'S,`SIGNATURE X �t t <br /> FOR-DEPARTMENT USE ONLY <br /> -Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE 11EAd ❑ January 1 &Received By January'31 ❑ July 1 &Received By July 31 <br /> } REMIT (t <br /> t; BILLING r;REMITTANCE $ AMOUNT DUE .,CHECKED <br /> CHECKED <br /> ., <br /> BASEEXPLANATION I <br /> k� DATE' -DATE REMITTED AMOUNT <br /> e r `4 <br /> FEES L_ <br /> LESST. <br /> PRORATION ( b-- •t„f f ' <br /> PLUS <br /> PENALTY{ <br /> {{ <br /> OTHER <br /> r 01 -- -r <br /> Received by ` Date Receipt No.., . Permit No. }' I suance:Date Mailed Delivered _ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMdISERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />