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APPLICATION <br /> of Non-Transferable,Revocable,and Suspendat' � �� <br /> ENVIRONMENTAL HEALTH PERMIT'=�- sC TAGE <br /> LIQUID WASTE <br /> ; Application is lie y mads to arty on uslness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) rr�� <br /> � Q,�Qg�.�i• Address l37c�'A <br /> Dwner Address <br /> Firm Partners, Addresses and I phone Numbers <br /> aBusiness Telephone No. �� 0 Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print) ,I s Title E L _ Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information ! <br /> I. ❑ 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. L!t;cnse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 1 <br /> No. of Vehicles Stared <br /> .No.of Chemical Toilets Stored <br /> �. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Ocation Test Date/Time <br /> 4. A SANITATION PERMIT <br /> Job Ad dre Locaii n S r (21 <br /> Owner Address • <br /> ❑ SEPTIC TANK ❑ CESSP OL %LEACHING FIELD SEEPAGE PIT ❑ PACKAGE'PLANT. C <br /> PERMANENT ❑ TEMPORARY 9L NEW REPAIR ❑ OTHER C^ <br /> 3. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 U <br /> Type Construction Disposal Site <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGETREATMENTPLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location Q <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. v <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County !, <br /> ordinances, state laws,ay rules aqd rfigulatips. f the San Joaquin Local Health District., <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is,Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received_By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> AMOUNTDUE CHECKED <br /> DATE DA E REMITTED AMOUNT . <br /> FEE L <br /> LESS <br /> PRORATION ! <br /> PLUS <br /> PENALTY ' <br /> OTHER t <br /> OTHER <br /> Received,by Date Receipt No. Permit No. Issuance Date Mail d;. Delivered <br /> APPLFCANT=RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIUSERVICES. 1601 E.HAZELTON AVE.,P.O.Box 2009 S.TOCKTON,CA 95201 <br />