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Applications Will Be Processed When Submitted Properly Completes rse aur 1 9r� 1P^��.^.�••�••• <br /> W APPLICATION C y <br /> gr [l�) SIwPTAGE <br /> I0r (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 1 LIQUID WASTE r <br /> Application is hereby made to carry on busin in the j ris ictionai area of the San Joaquin Local Health District <br /> y Busines Name (DBA) <br /> � Address <br /> aOwner Address <br /> 0 Firm Partners, Addresses... <br /> ddresses and T ho Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Pr`int)r Title ate Q� <br /> Please checkApplicableCategory (1-7)and Fill in the Required Information f� <br /> 11. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, ' June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> . License No. { CAL. License Renewal No. <br /> CAL <br /> Serial No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address _ _-^ ��---W -- —-' --.•- --_- ___."` . <br /> �2. ❑ PUMPER YARD r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3^'❑--PBRCOLAT'ION°TEST <br /> R.S. or R.C,E. No. r <br /> R.S.or R!C.E. Name # <br /> Test Loc+tionyt <br /> Test Date/Time ` <br /> 4. ❑ SANITATION PERM# <br /> Job Addess ocaY <br /> Owner Add ss _ <br /> ❑ SEPTdG TANK © C SPOOL LEACHING FIELD EEPAGE PIT . ❑ PACKAGE PLANT;. <br /> I] PERMANENT ❑ TEMPORARY EW EPA 13❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 <br /> Type Construction <br /> 4 Disposal Site = h <br /> No. of Units t Equipment Storage/Cleaning Location(s) <br /> fi. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> I Where Certified <br /> Operator'Name i I <br /> Plant Location I " <br /> Plant Caracit ) <br /> �� Urflts�Se <br /> d f t <br /> P y <br /> __7'_ <br /> �. -' i i <br /> 7. ❑ LtUNDRY For.July 1, -'June 30, 19 <br /> SIZE: 1r❑ Less Than 1,000 5q: Ft., ❑ More Than 1,000 Sq. Ft. f <br /> t�--0 S <br /> ❑ DRY ItLEANING, Chemicals U <br /> sed/Amount/Mo. i <br /> tt PrinG owner oriiconsedage RC' ibrt c,ra�"erflfiir.-,h'-: �Tfc��, � "i "' `hicl?this perm= isissued,lshallnotemployanyperson <br /> in such man net as to llacome suhjerl tt v:a+mo ,,cn,p^r:..li ,^n.; i <br /> C ntractor's hiring or sub-contractinu for which ti;is permit Is issued,I shall <br /> ei iploy persons subject to workman's compensatier.la"Ns ok <br /> I hereby certify tha ve prepare is app Ica ' nand that the work will be done in acc ce with O Joaquin County <br /> ordinances, s s,an nd r aftns he S Joaq Local HealthDistrict/ f <br /> APPLIC NT'S SIGNATURE X <br /> O� , <br /> e <br /> FOR DEPARTMENT USE Y I <br /> Fe' Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ J uary 1 &Received By January 31 ❑ July 1 &ReceiveRd Ehy July 31 <br /> EXPLANATION BILLING TTANCE $ AMOUNT DUE CHECKED <br /> BASE <br /> DATE /DATE REMITTED AMOUNT <br /> FE <br /> LE S t <br /> PR RATION <br /> PL S <br /> PE ALTY <br /> l <br /> OTHER <br /> O HER <br /> Rec by -.— Date Receipt No. Permit No. Issua a Da Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 ° <br />