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Applications Will Be `,#,essed When Submitted Properly Completed. Be L,,�To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application t�y ereby m de to car7-orl business in the jurisdictional area of the San Joaqu Local Heal Di trict <br /> w Business Name (DBA) VOW i D {UV 6 L p 1)Y" Address [�s��O x l� �J� <br /> iOwner Address <br /> 3 Firm Partners. Addresses and Telephone Numbers <br /> iBusiness Telephone No. !3 t - I s 2 Emergency Telephone No. <br /> Contractor Licence No r ,1 _ __ <br /> Appiicants Name (Print) �GJL.�!�}�D F L��� Title _ -- - -- __ Date - <br /> Please check Applicable Category (1-7) and Fill in the Required iiaormation <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 <br /> 3. ❑ P OLATION T T <br /> R'S. o C E. ameg-`o_ W R.S. C.E. NO. IZ'`i•9'�Q I a 30 N <br /> ->r--" <br /> Test Location �� 111-- ,��1EP_ RQ FSILM- � Test Date/Time __-_ _ --_--_ -_ — <br /> 4. ❑ SANITATION PERMIT MS '72- C7 1 3r{ '2 'TESTS WEST Dr- exls' Uhk� 4�odS� <br /> Job Address/Location <br /> Owner ------- - --- -- .— Aadress- --- - - - -- -- - <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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 _ <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 U eWAmount/Mo -- <br /> I hereby certify that I have prepareo this application and that the work will be done in accordance with San Joaquin County <br /> ordinances. state laws �, <br /> APPLICANT'S SIGNATURE X �J-f - ' ��!e ��-�' Title _--_-_-_ — Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UN;i ❑ PER SITE ❑ EACH ❑ January r 6 Received By January 31 ❑ July t 3 Received By July Jt <br /> r - --- - --- - --r---- REMIT <br /> BILLING T REMITTANCE 1 S AMOUNT DUE CHECKED <br /> BASE `"EX'PI-4''4 DA' DATE REMITTED AWUNT <br /> LESS <br /> PRORAT iON _� -- —--- --- <br /> PLUS <br /> P£NA(.TY <br /> OTHER I <br /> i <br /> OTHER <br /> eived by ate Receipt No Permit No Issuance Dili Mailed Delivered <br /> �.....s�e..:.�romr•ec --^- ���1 Tr1Y Avg On.aor'100a STOCKTON.CA 96401- <br />