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F Applications will be Processea wnen buommea Properly C:ompletea. tse sure t o sign i ne Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> :A, " <br /> LIQUID WASTE <br /> F Applicati hereby madexo carry on siness in the ju dictional area of theApn Joaquil. cal a . Dist_rici <br /> .n Business Name (DBA) 1r t 1d1.�T� 5—d - Address 3 0e 1 1nf_ <br /> {z Owner Address j c <br /> Firm Partners,Addresses and Telephone Numbers ot <br /> aBusiness Telephone No. — Emergency Telephone No. <br /> F <br /> Contractor Licence No.Applicants Name (Print) A O F� Title Date: RIZAfl– <br /> Please check Applicable Category(1-7) and Fill in the Required InformationF, r <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t y <br /> For July 1, June 30, 19 Disposal Sites - <br /> Description(Make/Y.r., Cblor)' - <br /> Serial No. CAL. License No. ' CAL. Licensel ff i;rtewal No. <br /> FCapacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, _ June'30 1.9 <br /> No. of Vehicles Stored <br /> # No. of Chemical Toilets Stored <br />( 3. ❑ PERCOLATION TEST <br /> F11R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job AddrePs/ oc tion - - <br /> Owner lit ATA Address ' <br /> i <br /> F ❑ <br /> W5FPTIC TANK 13 CESSPOOL ®''CACHING FIELD•. C 5 PAGF�'PIT PACKAGE PLANT <br /> U-PERMANENT ❑ TEMPORARY ®TEW REPAi IR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -,June 30, 19-- <br /> F, <br /> 9 _F, Type Construction Disposal Site r <br /> No. of Units _ Equiprnent.Slorage/Cleaning Logation(s) <br /> F6. ❑ PACKAGE TREATMENT PLANT For July 1„-,dune 30, 19-- <br /> j'i Operator Name 4` Where Certified , <br /> � t <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. <br /> r _ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Hoa'wownerpr9censedagent's olanaturecart iesthawkwPiliv,IcertiftyythatIntheperformanceorft*W cfarw"thispermitisIssued,Ishatinotem n r <br /> in such mariner as to become subject to workman's comperis '- n taws of Cafifprrt .•- employ any p!soil <br /> con"Mwa tri ' 01 ". 6-C.0rttrartin <br /> rs^ 9 aignQture Ilse Cern That in <br /> employ psrsgnt;sued to serorkzIan s cnm)er►sa;lan fa3 0 lffomia of °wark titr which this permit is issued,I shalt <br /> j ion'°an work will be done in accordance with San Joaquin County <br /> I hereby certify that I have pr life his applicatY, <br /> ordinances, state laws, and r d regulations of n Jo qi C ealth District: <br /> APPLICANT'S SIGNATRE X <br /> U <br /> FOA,,DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ElJanuary i &Received By January 31 ❑ Juiy 1 8.Received By July 31 <br /> REMIT <br /> BILLING FREMITTANCE $ <br /> BASE EXPLANATION DAT£ REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> F* LESSPRORATION <br /> PLUS �:.�•�' `� . <br /> PENALTY - / <br /> '. r <br /> t OTHER <br /> OTHER 76- <br /> Received <br /> Received by Date Receipt No. Permil No. Issuance Da Mailed Delivered <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.f-- ION .O.Boa 2009 STOCKTON,CA 95201 - <br />