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Processed When Submitted Properly o <br /> Applications Will Be <br /> APPLICATION g1=pTAGE <br /> " (For Non-Transferable,Revocabie, and Suspendable) <br /> ENVIRONMENTAL WASTE PERMIT <br /> LIQUID <br /> ob ness inthe.jurisdictionaarea the San'Joaquin Local Health District <br /> Applicaonishe ebymadetocarriAddress. <br /> mBusiness Name (DBA) Address _ 1 <br /> aOwner ~ <br /> u Firm Partners, Addresses and Telephone Numbers Emergency Telephone NO:—lip <br /> y <br /> lephone No ' <br /> a Business Te . _ / <br /> Contractor Licence No. GCS - r Title '""'°"{ Dater W <br /> �... . <br /> Applicants Name (Print) "► w �" A ' <br /> Please check Applicable Category (1-7)and YFlil in the Required Information <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal.Sites <br /> For July 1, June 30, 19 <br /> Description(Make/Yr.,Color) CAL.License Renewal No. <br /> CAL. License Na. _ <br /> Serial No. <br /> Capacity"_____ <br /> ^µGal-Weights-&Measures-No-—— <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 i <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name i Test Date/Time "• <br /> Test Location " <br /> 4. ❑ SANITATION PERMa <br /> Job Address/Location + v <br /> Address 4-17 <br /> r <br /> Own ` ❑ PACKAGE PLANT <br /> ❑ CESSPOOL FIELD ❑ SEEPAGE PIT ❑ OTHER �. <br /> ' �EPTIC TANK El NEW <br /> 11 REPAIR • <br /> 11 PERMANENT [3 TEMPORARY <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Locations) <br /> No. of Units <br /> 13PACKAGE TREATMENT PLANT Far July 1, -June 30, i9 <br /> g Where Certified <br /> Operator Name - <br /> Plant Location No. Units ServedT " <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 4 <br /> ❑ Less Than ,000 Sq. Ft., ❑ More Than 1',000 Sq�'Ft. <br /> 1 . <br /> SIZE: ` <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> prepared this application and that the work will be done in accordance with;S n Joaquin County <br /> i I hereby certify that I have prep <br /> ordinances, state laws, and rules and r Mations of the Suin Local HealtDistric <br /> APPLICAl SIGNATURE X <br /> FOR ARTMENT USE ONLYr <br /> f -'-. -+ January 31.' ❑ July 1 &Receivetl ByJuly 31 <br /> R ClER SITE ❑ EACH ❑ January i &Received By, REMIT <br /> Feels Due: ❑ ANNUALLY ❑ PER UNIT s CHECKED <br /> $ i I AMOUNT DUE <br /> - BILLING REMITTANCE - _ AMOUNT' <br /> BASE EXPLANATION' DATE TE REMITTED. -r <br /> FEES <br /> 1_ <br /> LESS <br /> PRORATION <br /> + l <br /> PLUM <br /> PENALTY <br /> OTHER _ <br /> �] •'y .�,,.�OT.FiER,.-,�-,..;rte"-' "'�"'"'-.+M- _ ... ... � F ,.. •�,� ��1 � � �.....d <br /> hoz 2009 S70CKTON,CA 45201 <br /> lssu ce D e Delivered <br /> NMailed <br /> Receipt No, Permit o- L <br /> Received by Dale - 1601 E.HAZ AVE.,P.O. <br /> 4 APPLICANT—RETl1RN ALL COPIES TO: -ENVIRONMENTAL HEALTH PERMlT1SEAVlCES <br />