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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> APPLICATION <br /> ` (For Non-Transferable, Revocable, and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ' hereby mad to carry onbusiness in h jupisdictional area of the San Joaquin Local Health Pistrict r <br /> �f3usiness Name (D A) Address <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. _?/cF S /C Emergency Telephone No. f <br /> Contractor Licence No. <br /> T <br /> L Applicants Name (Print). - <br /> -e�_ Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. 13.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 I . <br /> No. of Vehicles Stored - a <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 s� Test Date/Time <br /> 4. ❑ SANITATION PERMIT tom+► <br /> Job Addre s Locatio 7�- ?f J <br /> O�w��r zz Address <br /> Ls�1 Sr TIC TANK ❑ - SSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE/PLANT <br /> PLANT <br /> LQ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL,T_ OILETS For July 1, -June 30, 19 <br /> Type Construction - Disposal Site <br /> No. of Units r - 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 Used/Amount/Mo. <br /> I 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 rules nd regulations of San Joaquin Local Health District. x <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By Ja r ,y❑ July�ce d.By July 31 <br /> EMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE ECKED <br /> DATE DATE REMITTED .MOUNT <br /> _1 <br /> fEE S Lis <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER y <br /> OTHER 86 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed D livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES i601 E.HAZELTON AVE.,P.D.Box 2009 STOCKTON,CA 95201 <br />