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Applications Will Be Prortmsad When Submitted Properly Completed.Be Sure 1„Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT O L.)ED <br /> LIQUID WASTE <br /> Application i ereby made carry on bu mess in the'Uri$ ictional area of the San Joaquin Local He Mth Dff ct <br /> Business Name(D ) Address <br /> Owner Address - � <br /> 2.Firm Partners,Addresses and Telephone Numbers : <br /> Business Telephone No. 'D_'g Emergency Telephone No. <br /> Contractor Licence No. ZZ+r <br /> L Applicants Name(Print) Title 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 /" v <br /> Description(Make/Yr„Color) <br /> Serial No, CAL. License No. CAL.Liccnse 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 Stared <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.Name R.S.or R.C.E.No. <br /> Test L ation Test Date/Time t <br /> 4. tib SANITATION PERMIT <br /> Job Address/Location <br /> Ow er Address <br /> � 11WI <br /> , jS C TANK CESSPOOL 13" CHING FIELD IT ❑ PACKAGE PLANT <br /> LW PERMANENT ❑ TEMPORARY to NEW ❑ REPAIR ❑ OTHER � <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Co <br /> Type Construction Disposal Site <br /> Illi 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 /> 111 ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> F <br /> 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, and r and regulations of the San Joaquin Local Health District, <br /> APPLICANT'S SIGNATURE X <br /> M I <br /> III FOR DEPARTMENT USE ONLY <br /> !F Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 7&Received By January 31 ❑JUiy I a Received By Jury 31 <br /> I BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT RUE CHECKED <br /> AMOUNT <br /> FEE I? q5 <br /> i <br /> l LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> F I <br /> OTHER / <br /> f Received byDate Receipt No. Permit No. I ertce ate I, Deyvored <br /> 1+ APPLICANT_RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.aox 2009 STOCKTON,CA 96W ` <br />