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I Applications wilt tie rrocessea Wnen sut)mrttea Nropeny uompletea. be sure i o sign I ne Appucavon. <br /> APPLICATION <br /> rS, Non-Transferable, Revocable,and Suspendable, <br /> 0( <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUlO WASTE <br /> Applicatio ere Dy�made c on b ess in he' ris Tonal area of the S a uin ocal Health District <br /> �;Business Name (D Address� �c +- <br /> zOwner ddress '^- �. <br /> Q <br /> J Firm Partners, Addresses and Tele hone Numbers - <br /> a. Business Telephone No.' Emergency Telephone No. . <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Ca-egory�(1-7)and Fill in the Required Inf rmation <br /> 1. C1 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) u ` <br /> 'i For July 1, June 30, 19 I� Disposal Sites <br /> Description(Make/Yr., Color) k <br /> n <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity I' Gal.,Weights& Measures No. <br /> Equipment Parking Address <br /> €, Ig <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i1` <br /> i, No. of Vehicles Stored ;I <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST l <br /> a R.S.or R. .E. Name `� R.S. or R.C.E. No. <br /> Test L ation p Test Date/Time <br /> 4. SANITATION PERMIT .i' <br /> Job Address/Location �� <br /> O�,w�er - Address <br /> l� SEPTIC K ❑ CESSPOOL �EACHING FIELD T ❑ PACKAGE PL <br /> ❑ PERMANENT ❑ TEMPORARY �EW" ❑ REPAIR -1 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 6 <br /> Type Construction i� 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 i <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 <br /> it <br /> �i <br /> hereby certify that 61 have prepared this application and that the work will be done in accordance with San61aquin County <br /> ordinances, state laws, and ruI d regulations of the San Joaquin Local Health District. f�n� <br /> APPLICANT'S SIGNATURE X l� <br /> .i <br /> I FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY 7� ❑ PER UNIT ❑ PER SITE ❑ EACH January 1 &Rece January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> 'BILLING REMITTANCE <br /> BASEEXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE RITTED AMOUNT <br /> y FEE �I � L,7 <br /> a C� <br /> LESS <br /> j PRORATION <br /> 1 PLUS <br /> PENALTY <br /> OTHER <br /> OTHER 'I <br /> ,/ <br /> Received by Date Receipt No. Permit No. issuarice Date Mailed Delivered <br /> APPLICANT—A&URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.'Boe 2009 STOCKTON,CA 95201 <br />