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APPLICATION <br /> Non-Transferable, Revocable, and SuspendabN,,, <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is hereby made logr22��on business in the jurisdictional area of the San Joaquin Local Health District <br /> .�.usiness Name (DBA) L FLLaC. Address _/dy 1'4� eAeAeei'I[iL D 497 zz, <br /> aOwner__d - L• %U L�,e I t Address - -- — <br /> S' -irm Partners, Addresses and Telephone Numbers <br /> E 3usiness Telephone No. Emergency Telephone No. <br /> Con4t-actor Licence No. _ <br /> a Applicants Name (Print) Q L t=vGGLrY Title �u40`6 dr Date <br /> 'lease check Applicable Category(1-7)and Fill In the Required Information <br /> -9. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> .,?enal No. CAL. License No. CAL. License Renewal No. q <br /> Capacity -Gal.,Weights & Measures No. <br /> 'quipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> aakor July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> Vo. of Chemical Toilets Stored - <br /> tii. ❑ PERCOLATION TEST - <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location e Test Date/Time <br /> 1. <br /> ,0li0 <br /> SANITATION PERMIT <br /> JobAddrress/ ocanton <br /> O � /7 2 T3� V I Address <br /> PTIC TANK 1:1 CESSPOOL PACKAGE <br /> aJPLANT <br /> gi ..r <br /> -E`ACHING FIELD 11—0 PERMANENT ❑ TEMPORARY ❑ NEW' ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 <br /> Plant Location <br /> r <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 /> 1_ <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, and rul�nd�lat'of the San Joaquin Local Health District. <br /> IrAPPLICANT'S SIGNATURE X �..L9Tijlpi <br /> LFOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA ❑ January 1 &Received By January 31 ❑ July 1 6 Received By July 31 <br /> L BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE 5' 4 <br /> LESS <br /> 62 PRORATION <br /> PLUS / <br /> PENALTY <br /> OTHER <br /> V OTHER <br /> Received by Data - Receipt No. Permit No. Issuance Date Mailed Delivered <br /> V APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />