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MFlF7111:0OV117 tAlll WC"VI .. .—P-7 ,.,,...r.......... —,. ,-_._ ._ _.a.. ..._ <br /> APPLICATION I r <br /> ~'(for Non-Transferable, Revocable, and Suspend9ff/ SEPTA(-.E <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made t9 carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name(DBA) PL&IhI EM-6-H * P)o ,7A Address 5 <br /> i Owner •1�P�`; Address 7 _�L�1,/) S•r LDC71i GA _ --- <br /> Firm Partners, Addresses and Telephone Numbers - <br /> $ Business Telephone No. Emergency Telephone No. 14- <br /> Contractor <br /> ¢Contractor Licence No. <br /> Applicants Name(Print) TE?!� RIAZ-7A _ Title G Date 2 3 <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. Licrnas 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 StoredNo. of Chemical Toilets Stored -_ <br /> 3. C9 PERCOLATION TEST <br /> R.S.or ZE Name T P%PN-f P/'&Z.ZA R.S. or .C.E. No. <br /> Test Location ,1r'_' �- N�fl�� Beep - Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ ---- - -- - <br /> Owner Address - - - <br /> ❑ SEPTIC TANK ❑ CESSPOOL O LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30. 19 PAYMENT <br /> Type Construction _ Disposal Site _ _ €111M -- -No.of Units _ ___ Equipment Storage/Cleaning Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 r u <br /> Operator Name - — Where Certified SAN JOAQUIN COUNTY <br /> Plant Location _ PUBLIC HEALTH SERVICES <br /> Plant Capacity No. Units Served ENV� r t <br /> VMW <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19_ <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. `7'-) Y 2-- <br /> 0 <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. - - - - 7 <br /> I hereby certify that I have prepare a n and that the ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule nd regulati the San J in Local Health District. <br /> APPLICANT'S SIGNATURE X - L <br /> 2 ��T >NOL.�S PnP���L i oUD P4F�><L <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 Juty 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTAN � $ AMOUNT DUE CHECKED <br /> JAt <br /> DATE /QPL REMITTED AMOUNT <br /> FEE �� 2 �( �� - — -- <br /> LESS <br /> PRORATION -- <br /> PLUS <br /> PENALTY ___-- <br /> OTHER <br /> OTHER _ <br /> V <br /> 9 cewed by DatF Re ,,pt No Permit Nn Issuance Date Marled Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON.CA 95201 <br />