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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) GE <br /> ENVIRONMENTAL HEALTH PERMIT /NS - 9�.- /,92- <br /> LIQUID <br /> OZLIQUID WASTE <br /> Applicatio is heO ma arty o b s Hess in the jurisdictional area of the S n J rDi, t +' ��Or <br /> F Business Name (DBA)_ ry�� _� �• _Address . Ir• J <br /> Owner Add r s <br /> Firm Partners, Addresses an rel &1A <br /> e ,' _ � - <br /> iL Business Telephone No. �L_� _ _ _--_ - Emergency Telephone No. — <br /> Contractor Licence No._ <br /> a Applicants Name (Print) -'��1� £ Title _ - 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 Chemical Toilets Stored <br /> 3. XPERCOLATION TESLT/ T 3 <br /> R.S. or R.C.E. Name / 4wa /+ /IVLf _ R.S. or R.C.E. No. B <br /> Test Location /s AW- AM Test Date/Time "" 0� <br /> 4. ❑ SANITATION PERMIT ewl ?� <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 /> 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 /> 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/AmounUMo. <br /> I hereby certify that I have prepared this applicdllo nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and <br /> /r(/f and reg tios+9of he: In Joaquin ocal Health District. <br /> APPLICANT'S SIGNATURE X <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 July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> / <br /> FEE ! < �J .Z ,r ell '/ .�/ <br /> LESS // <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by J Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />