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Applications Will Be Proipessed When Submitted Properly Complel4d.IN OUre To Sign The Application. <br /> ND 2 APPLICATION <br /> (For Non-Transferable, Revocable,and Susperldable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> sLIQUID WASTE <br /> Application is hereby made torcarrAn business in the jurisdictional area of the San Joaquin Local Health District <br /> if Business Name (DBA) / Addregs_._____ <br /> aOwner M e-- ger q Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency/Telephone N0. <br /> Contractor Licence No. asp ✓� it <br /> Applicants Name (Print) ItleiP ® Date ,fit , <br /> Please check Applicable Category(1-7)and Fill in the Required In rmation <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 L ation Test Date/Time�_7________. <br /> 4. SANITATION PERMIT <br /> Job Address cation <br /> O.,wr Address <br /> SEPTIC TANK ❑ CESSPOOLCHING FIELD 11SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER �3J <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 p <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE'TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name __Where Certified �^ <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., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> 1 <br /> N <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ilk <br /> ordinances, state laws, and r4es and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X — <br /> FOR DEPARTMENT USE ONLY <br /> 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 $BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE aS. <br /> LESS �T <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Datil— Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />