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APPLICATION - - <br /> ,-(For Non-Transferable, Revocable, and Suspendav-e) SEPT O� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE M5.-92 _ S� <br /> Application is here b made to carry on bu mess in the jurisdictional area of the San Joaquin.1-9cal Health Dystrict <br /> Business Name (DBA) IJA4 j'I Address Z s fY� /5�U0/V�• ___ <br /> Owner/IC+ 1AtGf -,��:/lO�� ,�� �7Gd1 , <br /> Firm Partners, Addresses and Telephone Numbers Zo IF <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. Z <br /> Applicants Name (Print) _ Title Date Z 7!1-1 7-- <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. Chemical Toilets Stored <br /> 3. RCOLATION TEST <br /> R. .or R.C.E.Name _ R.S. or R.C.E. No. <br /> Test Location �. - y st Date/Time z-7-_S--w!? Z - __- <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location _ - -- -- -- - <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 - - <br /> OpwatOr 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 /> lfiswlsowrworlice�se+!ale»t'4s!-mats,r���,ft*hstl�e¢ogowyq;"1r,;r*isyt,atMthelsrrtarmsn ccGfth-workfor w`.ichth;s;t: mil isissued,lshallnetl!mp' ya»yDersor <br /> in such,TranRe as'a �re si 5' :':a •u;,.:, ,ttneti at+&R t,r s:•` <br /> Contractor's hFritp o: aut}eorTrrca y signature c�rWlep d+etufiumaty: i c;rtfty alai itt the pellormance of the work:cr wtsich:his perm;: issue <br /> I - <br /> employ persons subjL :u.vc...,..., ,,,r,l; nsacd r.'aHS o:C,:1lt0;jj_:' <br /> I hereby certify that I have prepared this ap -ca Y nand that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and and reg la th an Joaquin Local 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 /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> - - -rt- --- - -- p Co <br /> 110 <br /> FEE <br /> LESS D <br /> PRORATION <br /> PLUS <br /> PENALTY _ <br /> OTHER <br /> 12 1 O.� <br /> _ 1 <br /> _ [Its <br /> OTHER f1 <br /> - <br /> - Oalle Recel No --rm I No -- Issuance Date Mailed Delivered <br /> APPLICANT—MTURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..D.O.BOII 2009 STOCKTON,CA 95201 <br />