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APPLICATION <br /> �r Non-Transferable,Revocable, and Suspendabl <br /> >- ENVIRONMENTAL HEALTH PERMIT Si?TAG" <br /> LIQUID WASTE <br /> Application i reby made to garry on busin ss in the jI di ional area of the n Joaquin Local Health Distri <br /> yBusiness Name (D8 Address � 7,./, 7 � <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers {1} <br /> It <br /> Business Telephone No. :5a `ir Emergency Telephone No. 1 <br /> Contractor Licence No. !Z2;7_. <br /> L Applicants NamTitle Date r <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 36, 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. 11 PUMPER YARD 4 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PE OLATION TEST <br /> R.S.or .C.E. Name R.S. or R.C.E.No. <br /> Test cation Test DateTime <br /> 4. SANITATION PERMIT <br /> Job Address/Location Z j~ O <br /> O er vas Address <br /> I lPTIC TANK El CESSPOOL LEACHING FIELD SEEPAGE PIT '21jGK PA _ E PLANT 956 3 <br /> 1� PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑-OTHErR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site ` N <br /> No, of Units Equipment Storage/Cleaning Location(s) CA <br /> 6. 11PACKAGE TREATMENT eLANT For July 1, -June 30, 19 r a <br /> Operator Name Where Certified O <br /> Plant Location <br /> Plant Capacity No. Units Served' A- <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 /> f <br /> I hereby certify that I have prepared'thi�igppf cation and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 0) V <br /> FOR DEPAR ENT S ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ E ❑ January 1 &Received By January 31 0,July 1 &Received By July 31 <br /> BILL] MITTANCE $ REMIT . <br /> BASE EXPLANATION p T f .; GATE - REMITTED AMOUNT nUE CHECKED <br /> AMOUNT <br /> FEE '415, � <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Apr <br /> D-5 <br /> Received by Date Receipt No. Permit No. Is uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELT N AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />