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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �g <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to Qarry on busigess in the junsc(ic tonal area of the San Joaquin Local Health Dys trict <br /> w Business Name (DBA) R. e E SS C 41 X Address ��g"S CD/'01jR�O /�l/GfYLIiC <br /> a Owner LO[J� Trip Creep �i�P a� S Address ��� 1 () SOLI �� UT/�h _�0,fd <br /> Firm Partners, Addresses and Telephone Numbers <br /> Business Telephone No. { 43 - Z 0.2 Emergency Telephone No. _— <br /> Contractor Licence No. <br /> a Applicants Name (Print) Stan 5 /71A _ Title a 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 4 6 j / — 073. _ <br /> R, P CATION TEST /- l 7 r <br /> R S. o R.C.E. ame _ e Ce R.S. o R.C. o. y <br /> Test LocationWlaziin I-- _ Test Date/Time <br /> 4. 11SANITATIO PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER J <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 __ Y <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 certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> ,�(Q ,(� <br /> APPLICANT'S SIGNATURE X � � v����i1 — _ ._- Title.!ice/- Date v —`�a^ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> QLESSFEE _ 03 -e- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> (Z S -30 • "l1 6 ��-1c5Lp <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES .601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />