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ui� 1,.U6UJieU .vilt"ll >Uuuulieu l'IUtlefty k-uuiplewia, u� . ,Jm .0 a yu iPi4= f;Ppiiusuo i. <br /> n APPLICATION (f+,i <br /> (For -Transferable,Revocable,and Suspendable) ` / <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Application is Hereby made to carry on business in the jurisdictional area of the San Joaguin Local Health District <br /> F. - :41 - Address Vii=i G). <br /> stness Name (DBA) r Ifs �r <br /> /e, ••v " �- <br /> vner <br /> Address <br /> Fi Partners, AddressesI .and Telephone Numbers <br /> iness Telephone No. "�- `� Emergency.Telephone No. <br /> ntract6r Licence No. <br /> licants Name (Print) - <br /> Ilse check Applicable Category (1-7) and Fill in the Required Information <br /> ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> July 1, June 30, 19 Disposal Sites <br /> cription(Make/Yr„Color) — <br /> al No. CAL. License No. CAL. Rcnewal No.— <br /> Ipacity Gal.,Weights &Measures No. -- <br /> Ipment Parking Address <br /> 13 PUMPER YARD? <br /> >r July 1, June 30, 19 <br /> of Vehicles Stored <br /> of Chemical Toilets Stored <br /> ❑ PERCOLATION TEST <br /> S. or R.G.E. Name R.S.or R.C.E.No. <br /> Ft Location Test Date/Time <br /> ❑ SANITATION PERMIT _ C� <br /> Ib Address/Location 21- ''"'� .� ��� ' ' i'/4 - <br /> er i Address �i1 <br /> SEPTIC TANK CESSPOOLID <br /> AC1 LING FIELD ❑ SEEPAGI PtT ❑ PACKAGE PLANT <br /> ( PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 On <br /> Got <br /> e Construction Disposal Site <br /> Units Equipment Storage/Cleaning Location(s)— <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> -rator Name Where Certified <br /> nt Location <br /> lana Capacity No. Units Served <br /> © LAUNDRY For July 1, -June 30, 19 <br /> E: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state taws, and rules and ,dgu[a tions of the San Joaquin Local Health District. <br /> PLICANT'S SIGNATURE � ---- <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT a PER SITE ❑ EACH ❑ January i E,Received By January 31 ❑ July t &Received By July 31 <br /> BILLING REMITTANCE S REMIT <br /> ` r BASE EXPLANATION DATE GATE REMITTED AMOUNT DUE CHECKED . <br /> . AMOUNT <br /> FEE <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> G <br /> Received by Dale Receipt No. Permit No. Issuance Dale Mailed Delivered <br /> iii 4PPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTO ,CA 9S20T <br />