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r AIJFLIC:H'I IUN <br /> (Far Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT S[PTAGE <br /> LIQUID WASTE <br /> lessApplication i ereby mad�tocarrryon usinj ss in heju " dictional area of then Joa uin Local Health Distr" t <br /> Name A) ��` �+��laC'f1.� �kl-iG X�_ Address__ 't 7ra7 -� <br /> er 21�" z . C–_. Address__ 451 t <br /> ,Partners, Addresses and Telephone Numbers <br /> less Telephone No. -/x Emergency Telephone No. 1 <br /> Tactor Licence No. <br /> cants Dame (Print) ' Title Date -2 <br /> e check Applicable Cal (1-7)and Fill in the Required Information -9 <br /> PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> July 1, 'June 30, 19 Disposal Sites <br /> Fription(Make/Yr.,Color) <br /> I No" CAL. License'.No, CAL.License Renewal No. <br /> !city Gal.,Weights&Measures No" <br /> ment Parking Address <br /> ibPUMPER YARD <br /> July 1, June 30, 19 , <br /> :)f Vehicles Stored <br /> 1f Chemical Toilets Stored <br />! � PERCOLATION TEST <br /> I or A.C.E. Name R.S.or R.C.E.No. <br /> ation Test Date/Time .� <br /> SANITATION PERMIT <br /> i <br /> Address/Loc ion <br /> r Address / 3 7 - - J f L" V Y f w_ <br /> LEPTIC TANK ❑ CESSPOOL LEACHING FIELD 0—SEEPAGE PIT' 0 PACKAGE PLANT <br /> ERMANENT ❑ TEMPORARY ❑ NEW 0-IfEPAIR ❑ OTHER <br /> 3 CHEMICAL TOILETS For July 1, June 30, 19 <br /> FConstruction Disposal Site -C <br /> �f Units Equipment Storage/Cleaning Location(s) <br /> PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> ptatorNaWhereCertified _..... <br /> Lation. <br />{ i Capacity No. Units Served <br /> LAUNDRY Fpr July 1,-June 30, 19 <br /> ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> IFRY CLEANING,Chemicals Used/Amount/Mo. <br /> hereby certify that I halie'prepared this application and that the work will be done in accorc�nf�with San Joaquin County <br /> ordinances,state laws,and rules and gulations of the San Joaquin Local Health District" 1� <br /> F-ICANT'S SIGNATURE X L .J <br /> r FOR DEPARTMENT USE ONY E. <br /> Fee 15 Due; ElANNUALLY 11 PER UNIT 0 PER SITE ❑ EACH - ❑ January- & eived By January 31 ❑July 1 8 Received By July 31 <br /> BILLING REMITT .CE $ REMIT <br /> F <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DAT REMITTED AMOUNT <br /> FEF <br /> LESS <br /> 3 PRORATION <br /> PLUS <br /> PENALTY <br /> i <br /> OTHER <br /> F OTHER <br /> o I <br /> IV <br />' Received by Date Receipt No. Permit o. Issuance Dale Mailed livered <br /> FL— APPLICANT—RETURN ALL GOES TD: ENYlRONMENTAL REALTH PERMlTlSERYICES 1601 E.HAZELTON AVE.,P.O.Hos 2009 STOCKTON,CA 95201-- <br />