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>{ <br /> Applications Will Be Processed When Submitted raper y _.s t..Ai; <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SFPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE ` <br /> Application i hereby made to car n siness in the jurisdictionalAatea Ost San` quin L cal Health D C <br /> '� 5r_ • <br /> U) Business Name (DBA) Address - f <br /> i Owner " <br /> a Telephone Nor <br /> n Firm Partners, Addresses and Telephone Numbers Emergency p X <br /> a Business Telephone No.. ... <br /> _ Date. ' <br /> Contractor Licence No. _ Title. _ = J <br /> Applicants Name (Print) rfsls ,"lin, — <br /> Please check Applicable Category (1-7)and Fill In the Required Information-. ,. � <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR o EACH <br /> al VEHICLE) -- <br /> DispForJuly 1, — June 30, 19 <br /> CAL.License Renewal No. <br /> Description(Make/Yr,, Color) CAL. License NO., <br /> Serial No. * j <br /> .Gal."Weights'&Measures No. <br /> Capacity- <br /> Equipment Parking Address f-- <br /> 2, ❑ PUMPER YARD ix; r <br /> For July 1, June 30, 19 <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.G.E.Name Test Date/Time i <br /> "� ; F ► ° <br /> Tet i,ocation <br /> 4. NiTATION PERMIT <br /> Job Address/Location Addre <br /> &We ❑ PACKAGE P ANT <br /> PTIC TANK ❑ CESSPOOL ��ACH�IN� IELD SEEPAGE PIT ❑ OTHERY <br /> ❑ REPAIR❑ TEMPORAR <br /> RMANENT t <br /> 5, 13CHEMICAL TOILETS For July 1, -June 30, 19 <br /> *Disposal Site 4 �� �; <br /> Type Construction I �_ <br /> Equipment Stofage/Cleaning Location(s) - r, <br /> No. of Units - R. :.sr V <br /> June 30, 19 t € <br /> B. 11 PACKAGE TREATMENT PLANT For July #,-F , Wtiere Certified c <br /> Operator Name <br /> Plant Location _ No. Units Served - • " <br /> ` Plant Capacity I <br /> 7. El LAUNDRY For July 1, -June 30, 19 t <br /> ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft" w r <br /> SIZE: " + <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. hich this permit is iss- l sfit ll <br /> Hoo ownsr or licensed agert's ssgneturc sertlfi9sthefioltawtng:"l certlfg that in Cita performance nt the�rrork farwu a pct anploy any person <br /> Horne <br /> in suets manner as to he0mr suiiiect 10 WOrkwvl s Gtmlaensatiori laws of Catiiorni2 <br /> contractor's hiring or sub-contmctincr aipInature certifies the following: -"I certify that its thaperformance of the;vortc tar Which this perm it is Issued,i shall <br /> Employ persons 5uhject to workman's compensation(avis of Caiif9Tria.'- ! - <br /> I hereby certify that I hav'�prepared this applic do and'th a wo will be done in accordance with San Jaiquin Cou�nt'`/1, <br /> r <br /> ordinances, state laws d ,sand+- ions f S Jo uin Lo IH <br /> ealth District. <br /> APPLICANT'S SIGNATURE X r <br /> F <br /> A' <br /> t <br /> " FOR DEPARTMENT USE ONLY <br /> PER UNIT ❑ PER SITE ❑ EACH ;❑ January 1 &Received By January 31 ❑ July 1 &Received REMBy IT 31 <br /> Fee,,ls Due: ❑ ANNUALLY ❑ REMITTANCE $ AMOUNT.DUE� CHECKED <br /> BILLING REMITTED AMOUNT <br /> kf'~ BASE. EXPLANATION DATE DATE - <br /> FEE <br /> LESS l <br /> tPRORATION + <br /> r IPLUS t y _ <br /> PENALTY ` <br /> OTHER <br /> .OTHER,.4,.,y r <br /> -r Permit Na +. 1 uance ate Mailed Delivered' <br /> Date Receipt No. 1601 E.HAZELTON AYE.,P.O.Sox 2009 STOCKTON,CA 95201 <br /> Received by <br /> APPLICANT—RETURN ALL COPIES 70: ENVIRONMENTAL HEALTH PERMITlSERVICES # <br />