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.,�. . <br /> Applications Will Be Processed When Sub APPLICATION <br /> +I <br /> (For Non-Transferable, Revocable,and Suspendable) SEP7AGE <br /> ENVIRONMENTAL. HEALTH PERMIT i <br /> LIQUID WASTE �7 <br /> Application ' hereby mad .1131,;11,11Y,business in thelurisdictional area of the SJoaquin-Local Health Distri V' <br /> Address <br /> BusinIss Name (D 1 <br /> zz Owned+: <br /> u Firm Partners, Addresses and Telephone 7pNumbers Emergency Telephone No. <br /> $ gusiri�ess Telephone No. <br /> Contractor Licence No. -'7", Date <br /> Title <br /> Applicants Name (Print) <br /> Plea4'check Applicable Category (1-7) and Fill in the Required InformationJr <br /> 1. ( 1. PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Desclflption(Make/Yr., Color) CAL. Lic--1se Renewal No. <br /> Serial No. CAL. License No. <br /> k 1 iGal.,Weights & Measures No. <br /> Cap <br /> Equipty <br /> ment Parking Address 1� <br /> 2. IB PUMPER YARD l <br /> For July 1, June 30, 19 <br /> l No. of Vehicles Stored <br /> No. �of Chemical Toilets Stored <br /> 3, ED PERCOLATION TEST R.S.or R.C.E. No. <br /> F�.S.��or R.C.E. Name Test Date/Time <br /> Test Location ` <br /> 4. ID SANITATION PERMIT <br /> JobjAddr s Location Address <br /> IO)w/ r I] PACKAGE PLANT <br /> L+4' PTIC TANK 11 CESSPOOL L`1 ACHING FIELD SEEPAGE PIT ❑ ETHER <br /> PERMANENT 13 TEMPORARY NEW <br /> ❑ REPAIR <br /> 5. � CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> Noj1Iof Units <br /> 6. 1I1:1 PACKAGE TREATMENT PLANT For July 1,- June 30, 19 Where Certified <br /> I Operator Name <br /> Plaint Location No. Units Served ^ <br /> Plant Capacity A <br /> 7. 11 LAUNDRY For July 1, -June 30, 19 <br /> Than 1,000 5q. Ft. �l <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 11 <br /> El!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 /> I ' ordinances, state laws, and rules and re I tions of the Sa qu Local Health District. <br /> I <br /> I <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> July 1 &Recei <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ veRdJuly 31 <br /> EMIT <br /> i' $ CHECKED <br /> BILLING REMITTANCE AMOUNT DUE <br /> _ BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I G ✓ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ij OTHER - . <br /> jS 1530 p Mailed Deliver d ' <br /> I Receipt No. Permit No.• ' <br /> !! <br /> Receivedby _ Date .'1601 E.HAZELTON-AVE.,P.O.Boa 2009 ST G TON,CA 95201 - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PER <br /> MIT <br /> /SERVICES <br /> �r � <br />