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APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat'on is hereby made to carryon businesSya�p the j ris Ictional area of thASan�oaquin LocalHealthDiisstrict-_ <br /> w Business Name (DBA) i F w a H A "rlC Address <br /> i Owner =F �A I A,LT�.�}L•l Address�d <br /> Firm Partners, Addresses anpd TVClephone um Is <br /> 'E. Business Telephone No. -1 0 y -�A ' Emergency Telephone No- I <br /> Contractor Licence No. _ <br /> Applicants Name (Print) I I= g= !�Isj A"LzV )A al L . Title Date <br /> ZL <br /> Please check Applicable Category(1-7) and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) .nJ <br /> For July 1. June 30, 19 Disposal Sites -- <br /> Description(Make(Yr.,Color) -- — <br /> Serial No. CAL License No. --CAL.Liccnse Rencwal 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. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name __ R.S.or R.C.E.No. , <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PER T <br /> Job Ad dr ss/Location <br /> Owner f A L r- ,o Address <br /> 13 <br /> ❑ SEPTIC TANK CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER 1 <br /> S. ❑ 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 Q <br /> _ Where Certified <br /> Operator Name <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 certi hat I have prepared this applic .on and that the work will be done in accordance with San Joaquin County <br /> ordinances. state , and mules reg fall s the S Joaquin Local Health District. <br /> APPLICANT'S SIGNATI)R� �~ <br /> 'ot FOR DEPARTMENT USE ONLV�; <br /> Fee Is Due: ❑ wREMIT <br /> ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &RecerveA 9y January 31 ❑ July 1 &Recerv!By JulY 31 <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE .. DATE REMITTED AMOUNT <br /> FEE <br /> �f5 <br /> LESS — <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER -- -- <br /> OTHER - <br /> �APPC ANT-RETURN AU COPIES TO: ENVIRONMby fiatePENTAL HEALTH PERMIT/SERVICES 1601 E I HAZELTONIAVE.,P.O..aaaie2009 SDTOCK a N.CA 9201 <br />