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Applications Will Be P. ssed When Submitted Properly Completed. Be :To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> a Business Name (DBA) LILe�� t i'�Iv:2Pli5l Address P.C`. 8��k <br /> i Owner_ /tr+k' til STMeNT C IM/T�D Address fo-cv t4*Vac4. wD C JI <br /> --- <br /> Firm Partners, Addresses and Telephone NumbersIL <br /> a. Business Telephone No �_� �� -� 3p �� f 3 Emergency Telephone No. <br /> Contractor Licence No. 18/ y <br /> Applicants Name (Print) LC Title _5I--VE`101L _ Date <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, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL License No. CAL. License Renewal No. <br /> Capacity - _ Gal., Weights & Measures No <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, _ June 30, 19 <br /> No. of Vehicles Stored <br /> No of Che (lets Stored <br /> 3. EkIVERCOLATION TEST <br /> R.S. or R.C.E. NameR.S. or R.C.E. No. <br /> Test Location -_ _ L =SCA. _ Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner _ - Address - - - - - -- - --- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1. - June 30. 19 .� <br /> i <br /> Type Construction Disposal Site <br /> No of Units _._ Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 _ <br /> Operator Name — - - __- -- _ Where Certified .�.--r .,n <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 /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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 laws. l� / <br /> APPLICANT'S SIGNATURE X Title ' jvlcLt f/ty� Date1.-�i� <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Perm t No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E-HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />