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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SgPTAGi O <br /> II LIQUID WASTE <br /> Application is-hereby made carry on business in the jurisd' tional area of the n Joa in Local Health Distric <br /> �—• <br /> ,F Business Name (DRAt Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. S <br /> a Emergency Telephone No. <br /> Contractor Licence No. Z- <br /> L Applicants Name (Print). Title Date <br /> Please-check Applicable Category (1-7)and Fill in the Require nlormation <br /> t. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July1',' a- `June 30' 19 N Disposal Sites, <br /> Description.(Make/Yr., Color). i! <br /> Serial No. • iii CAL. License No, <br /> CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No.' <br /> Equipment Parking Address ai <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored '! <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST 1! <br /> R.S. or R.C.E. Name <br /> R.S.or R.C.E. No. <br /> Test L .- Test Date/Time �4 V <br /> 4. SANITATION PERMIT -^ <br /> 2 � <br /> Job Address/ alio / � '.� <br /> fis <br /> rddress 'PTIC TANK ❑ CESSPOOL tt� ��,, L��CHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> RMANENT ❑ TEMPORARY #.0 NEW .; ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For Ju y;1;+-June 30, 19 � + <br /> Type Construction .I *r,:DisposaleSi h <br /> •- <br /> No. of Units rc " 'Equipment Storage/C leaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLAN_ T For July 1, -Ju'e 30,"19 <br /> Operator Name ---- �,.�„�_-„„-�WhereCertified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq:Ft.,i,- [ .-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, anVru119"hnd regulations ofan Joaquin�Localistrict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ' <br /> if <br /> Fee Is Due: ❑ ANNUALLY ❑!PER UNIT PER SITE ❑ EACH ❑ January 1.8 Recekved,By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> RASE EXPLANATION A <br /> DATE DATE REMITTED MOUNT DUE CHECKED <br /> AMOUNT <br /> FEE / <br /> LESS e_ <br /> PRORATION I� <br /> PWS <br /> PENALTY 4 <br /> OTHER I! <br /> OTHER it # <br /> Received by Date AReceipt No. P <br /> L <br /> ermit No. issuance Date Mailed elivered / <br /> APPLICANT--RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 1601 E.HAZELTON AVE.,P'OO.fB2�0y09 S`TOCCKT ,.CA 95201 i <br />