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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Appficatfon:--- <br /> APPLICATION <br /> q4 (For Non-Transferable,Revocable,and Suspendable) <br /> ! ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> ' ` ` LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> w lusiness Name (DBA)_ McT3ona1 a Sp t i T ri Sprvi CP- Address---4645 Hi 1 do-t--h Y,an ' <br /> z Owner rr MnTlnnal r? <br /> -C Address_ S2ITt2 <br /> 0 Firm Partners,Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No" Q3T _n!}}7 Emergency Telephone No. 957-4027 <br /> Contractor Licence No.. 3081 ]1 <br /> 4 Applicants Name (Print)T— R MCT)nna7 r3 Title Own it-r <br /> Date <br /> Please check Applicable Category(1-7)and FIII in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 v Dis sal Sites � � � <br /> ... p r <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL.License Renewal No. <br /> Capacity Gal.,Weights 8 Measures No <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARDM �7- <br /> For July 1, June 30, 19 +� <br /> 46 <br /> No.Of Vehicles Stored f <br /> No. of Chemical Toilets Stored---- <br /> 3. <br /> tored 3. ❑ PERCOLATION TEST - . '" •-..-�. <br /> R.S.or R.C.E.Name ' <br /> No. <br /> Test Location 'Test e/Time <br /> 4. ❑ SANITATION PERMIT t i �" (�`+^+•.-fit ,�1 S� 1 <br /> Job Address/Location _ <br /> Owner <br /> = Add essA <br /> SEPTIC TANK ❑ C SSPOOL t LEA6HING FIELD _ PAGE PIT ❑ PACKWE PLANT <br /> PERMANENT ❑ TEMPORARYNEWS REPAIR 13OTHER <br /> 5. <br /> 13 CHEMICAL TOILETS For July,1,-Jun 30, 19 <br /> 'e Construction <br /> Disposal Site <br /> orunits• 1- a Equipment Storage/Cleaning Location(s) <br /> s 6. ❑ PACKAGE'TRE•ATMENT.PLANT For July 1,-June 30, 19 <br /> Operator Name <br /> Where Certified j <br /> Plant Location - 4 <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 /> R <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 and regulations of the San Joaquin oval Health District. <br /> APPLICANT'S SIGNATURE X , <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT id PER SITE ❑ EACH ❑ January 1.&Received By January 31 ❑ July t&Received By July 31 <br /> BASE BILLING REMITTANCE $ REMIT <br /> EXPLANATION AMOUNT DUE CHECKED <br /> DATE � DATE REMITTED AMOUNT <br /> FEE ys . " <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Pers. i suoan a Oats- Malleo a ae <br /> • APPLICANT—RETURN,ALL COPIES TO` ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Bow 2008 'STOCI.ON,CA 201 ' <br />