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APPLICATION <br /> -Transferable, Revocable;and Suspendabt f SEPTAP�aIRONMEW <br /> GE <br /> AL HEALTH PERMIT, <br /> LIQUID WASTE V <br /> Applicati hereby made4o carry onjasiness in the j diction-al area of the,&an Joaqui cal a Distric <br /> ,F Business Name (DBA) f7F �zxc�Tc� Address <br /> aOwner Address _�#J <br /> ,Firm Partners, Addresses and le hone Numbers <br /> aBusiness Telephone"No. '.S35a2 Emergency Telephone No. <br /> Contractor Licence No. . . <br /> Applicants Name (Print) Title Dat <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, - c- June 30,-1g Disposal Sites <br /> Description(Make/'(.r C°Wrl,_A_ <br /> Serial No. CAL. License No.. ` CAL. Licensedi�Dlawallslo. <br /> Capacity Gal.,.Weights &Measures No. ; <br /> Equipment Parking Address ) <br /> 2. ❑ PUMPER YARD <br /> For July 1. Jun64P�Ql9 <br /> No. of Vehicles Stored a <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATIONTEST <br /> R.S.or R.C.E. Name 1.11 R.S.or R.C.E. o. <br /> Test Location `+ Test Dato%Time ' <br /> 4. ❑;SANITATION PERMIT �� , ;J s <br /> Job Addre s/ OC tion f <br /> Owner �� ) Address 4 <br /> U-S PTIC TANK ❑ CESSPOOL LtAGHIIVG FIELD.1.11 QP'§_EE�AGIT '-D--PACKAGE•-PL-ANT., <br /> `9�-PERMANENT ❑ TEMPORARY Q-1EW REP-6716 ❑ OTHER <br /> S. 11 C_ <br /> TOILETS For July 1, Jun 30, 19 •, <br /> rte' <br /> Type Construction Disposal Site 3 <br /> No. of Units Equi'onent�.Storage/Cleaiiing Locatldn(s) �y <br /> 6. ❑ PACKAGE TREATMENT PLANT For J4 1,/'�wne 30, 10- <br /> ,Operator-Name <br /> $;Operator Name Where Certified <br /> Plant Location J'Z <br /> Plant Capacity y No. Units Served t <br /> 7. ❑ LAUNDRY For July 1, -'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 /> Z,such anI'lorlmdrilTastO ecOrgeubject owork( aft' the folt¢Aaeq:`lCErti tatlntlkl(9lki inCe4iNiewOricfAt ' <br /> insuchmannerastobecnmes�hjecttBlrprkntan's.tonlp> tawsQtC +"' 3�armFtlslssued. shallRate�rlployranyptrsoa <br /> s w arabceeltrecting aL-- <br /> employWiurs BI. <br /> ptts@n6 t4[trfeiGt to war#cman's compensation la o ifarilia" #i Awwmattp of! wotk fir which this PeMit is issued,I shall <br /> hereby certify that I have pr a his application: n work will be done ir1 acardance with San Joaquin County <br /> ordinances, state laws,and r d regulations of n Joam c ealth District. <br /> APPLICANT'S SIGNATURE X <br /> 13 <br /> - - Y QP <br /> FORIJDEPAR.TMgNT USE ONLY <br /> Pee IS Due: 13 ANNUALLY PER UNIT. 11 PER SITE ❑+JzACH I ❑ January'1 &Received By January 31 C3 July 1 &Received By July 31 <br /> REMIT <br /> BIL <br /> BASE EXPLANATION ING °REMITTANCE $ AMOUNT DUE CHECKED <br /> D' TE ; DATE REMITTED i AMOUNT - <br /> FEE ' i <br /> LESS ' <br /> PRORATION <br /> ., <br /> PLUS _ <br /> 'PENALTY <br /> OTHER <br /> OTHER <br /> Received 6y Date Receipt No. Permit No. .Issunce Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: - ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON . .O.Box 2009 STOCKTON,CA 95201 - <br />