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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) $1=pTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT <br /> LIQUID WASTE <br /> A lication Is reb made carryon mess in the risdictional area of the ,n�joa In Local 7 alIl etrict <br /> N Business Name (DBA)_ p- �'' Address W� / <br /> aOwner Address a <br /> J Firm Partners, Addresses and Telepho a Numbers _.. <br /> 0. Business Telephone No, s `?,6 Q Emergency Telephone No. <br /> Contractor Licence No. . <br /> �Applicants Name (Print) ; Title. Date I <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,'- June 30, 19 Disposal Sites '— <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL.'License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ocation Test Date/Time <br /> 4. SANITATIONPERMITr� _ w <br /> Joh Address/ oc tion /�� <br /> PU <br /> Owner ' M6V - Ml L S � - Address °p <br /> 0 SEPTIC TANK 1:1CESSP_OOL ❑ LEACHING FIELD 0 SEEPAGE PIT 0 PACKAGE PLANT <br /> 11PERMANENT" El TEMPORARY - . ❑ NEW MeIREPAIR J40THER j?A*4V FE-P �(I <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction } Disposal Site <br /> 4 <br /> No. of Units f Equipment Storage/Cleaning Location(s) t eft-. <br /> 6. ❑ PACKAGE TREATMENT.PLANT . For July;1, -June'130,�19 N :� <br /> `_ V ,; ) i - 0-- Where Certified <br /> - Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served ( �. <br /> 7. ❑ LAUNDRY For July 1, June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0ore Than 1',000 Sq: F_t. <br /> 'L. +. <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. <br /> s I hereby.certif7.that,l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> I 6edinadcbr state laws, and rules d regulation of the S o pain L ca Health District. I <br /> I <br /> oo <br /> APPLICANT'S SIGNATURE X`! <br /> FOR OEPARTMEN'T USE ONLY­-- <br /> Fee <br /> NLY"-Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 ' <br /> REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION .4. DATE -DATE REMITTED1 <br /> e AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER - <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mail ' ,Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O. ox 2009 -STOCKTON,2_9 <br /> 01 <br />