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APKICATION _ <br /> (For Non-Transferatrle,•.levocable;.arld Suspendable) <br /> ENV1R0'14IWIENTAL HEALTH PER'MT <br /> T p ,^ <br /> LIQUID 1hIASTE <br /> Applicata is reby made to car on business in the sdictional area of th San Joaquin Local Health District <br /> Business Name (DBA} � > �a <br /> Owner Address!=p p <br /> Firm Partners. Addresses and Telephone Address <br /> Numbers <br /> Business Telephone No. <br /> Contractor Licence No. Emergency Telephone No. <br /> Applicants Name (Print) <br /> Date. <br /> Please check Applicable Category(1-7)and Fill In the Required information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r� <br /> For Jul 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. GAL License No. <br /> Capacity Gal., Weights &Measures No, CAL. License Renewal 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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name <br /> Test Lg�att�n FLS, or R.C.E.No. <br /> 4. SANITATION PERMIT Test Date/Time t <br /> . 1 <br /> Job Address/Location <br /> ,Ow r Address ✓` 0 <br /> SEi�TIC TANK ❑ CESSPOOL LEACHING FIELD ���J <br /> ❑'PERMANENT ❑ TEMPORARY BNEW PAIR PIT ❑ PACKAGE PLANT <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 © REPAIR ❑ OTHER <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 g <br /> Plant Location Where Certified <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE. ❑ Less Than 1,000 Sq. Ft., 13 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that I e prepared this application and th t the work will be done in aceordancd`i with San Joaquin County <br /> I <br /> ordinances, stateis Anreg ulatlo s f the S Joa Local <br /> q n Kealih District. <br /> APPLICANT'S SIGNATURE i'; <br /> FOR DEPARTMENT USE ONE <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ AN f ❑ Japuaq- <br /> ReceivedBy January31 <br /> ❑ July 1 &Received ay Juiy 31 <br /> SASE EXPLANATION BILLIN R ITT J1 ' - REMIT <br /> D ;T REMITTED AINOLINT DUE CHECKED <br /> FEE 4f - ; AMOUNT <br /> !! CJ .` r' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �- <br /> OTHER z <br /> OTHER <br /> Received by pate Receipt nlo, / <br /> APPLICANT—RETURN ALL COPIES TO, ENVIRONMENTAL HEALTH PERMITPer <br /> 5ERy CESIssuance pale Mailed Oeliveretl �/ <br /> 1601 E.HAZELTON AVE.,P.O.%a 2Q08 STOCKTON,CA 95201 <br />