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Applications Will Be Processed When Submitted Properly Completed..Be Sure To Sign The Application. <br /> / APPLICATION <br /> r� (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP`fAGE <br /> LIQUID WASTE <br /> Applicatio tsYhereby e carry., busin s in the jurisdictional-area of the Sa. O quin L I He h Distri <br /> wBusiness Na (DBA) ��J1 5P �- f Address �(�] <br /> z Owner Address <br /> a , <br /> a Firm Partners, Addresses and Telephone Numbers F E O Y�' <br /> CL <br /> Business Telephone No. �'�raa�'- Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants NamTitle Q L<? - Date QS . <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 July 1, June 30, 19 Disposal Sites o <br /> Description(Make/Yr., Color) II <br /> S <br /> Serial No. CAL. License No. CAL. Liccnse Renewal No. j <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. ❑ 'PERCOLATION TEST <br /> R.S. or R.C.E. Name_ R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑"SANITATION PERMIT <br /> Job AddP(.Im <br /> s/Locatio <br /> C 1. <br /> e <br /> o <br /> OwnerAddress <br /> SEP TANK ❑ CESSPOOL i�3'LEACHING.FIELD R'SEEPAGE PIT ❑ PACKAGE PLANT <br /> M-�PN <br /> ERMANENT 111:1TEMPORARY El-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) C <br /> 65. 11PACKAGE TREATMENT PLANT For July 1, -June 30,`19 <br /> Operator Name Where Certified i <br /> Plant Location { <br /> Plant Capacity No. Units Served '1 <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 as <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 9, � <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> herebycertify that i have re this aAllil, eahat the work will be in accordance with San Joaquin County <br /> Y Pordinances, statelawsand es nd re ulaJoaquin Local Heft istrict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMEN SE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EA ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 ' <br /> BILLING RE-ITTANCE REMIT <br /> $ - �! <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received byDate FlSpffipt No. Permit No Issuance Date Mailed Delivered ._ <br /> APPLICANT—RETURNAL.L COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICE 1601 E.HAZE ON AVE.,P O.Box 2009 STOCRTON,CA 95201 <br />