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Applications Will Be Prot d When Submitted Properly.Completed. Be Sur Sign The Application. <br /> APPLICATION — <br /> (For Non-Transferable, Revocable, and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ` LIQUID WASTE <br /> �"' Applicatio is re m tt�rry on s ess i t jurisdictional area of the an/Joaquin Local Heal P <br /> 7 Busmes e.(DBA) Address ' ��� � <br /> )canerAddress <br /> j--irm Partners, Addresses ahi 1 Tl le hone Num am fir <br /> L Business Telephone No. u ��1 Emergency Telephone No. <br /> "'Ontractor Licence No. _ <br /> Ltpplicants Name (Print) ��-� E£ Title QW•� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information p� <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) I- <br /> -or July 1, June 30, 19 Disposal Sites <br /> �eJescription(Make/Yr.,Color) <br /> Serial No. CAL.License No. CAL. License Renewal No. <br /> rapacity Gal.,Weights &Measures No. <br /> equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> cor July 1, June 30, 19 <br /> Vo.of Vehicles Stored <br /> `No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> I.S.or R.C.E. Name R.S.or R.C.E.No. <br /> ..restrt Location Test Date/time t <br /> 4. SANITATION PERMT <br /> lob Addres cat <br /> rn <br /> Dw er Address <br /> = <br /> PP(��$EPTIC TANK ❑ CESSPOOL LEACHING FIELD ('SEEPAGE PIT El PACKAGE PLAN <br /> ERMANENT ❑ TEMPORARY 'ErNEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> aiiii,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/Amount/Mo. <br /> r <br /> 1 hereby certify that I have pre this applicatio nd th the work will be done in accordance with San Joaquin County C;t <br /> ` ordinances,state laws,and r es an reg ions of a oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> ` BILLING REMITTANCE E <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> (� <br /> AMOUNT <br /> FEE �Y' a v <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY \\\� <br /> OTHER <br /> OTHER <br /> ` Issuance <br /> Received by Date Receipt No. Permit No. Uele Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bo.2009 STnnv+n•' <br />