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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r'/ APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) Address rc.��� �� �- Address <br /> z Owner AddressE- - <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. BusinessTelephone No. Emergency Telephone No. <br /> _J Contractor Licence No. <br /> Applicants Name (Print) Title Date <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. i CAL. License Renewal No. <br /> 1 Gal.,Weights & Measures No. I ' <br /> Equipment Parking Address, I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19w A <br /> No. of Vehicles Stored <br /> No. of 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 cation Test Date/Time, ; <br /> 4. 15 SANITATION PERMIT fir_ Y <br /> Job Address/Location —17 'sr <br /> O_,w/�er—��[=r�- Address <br /> L� SEPTIC TANK IJ CESSPOOL 5IFACHING FIELD a T ❑ PACKAGE PLANT, <br /> I(PERMANENT ❑ TEMPORARY lJ NEW ❑ REPAIRS ❑ OTHER W <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 fi <br /> Operator Name Where Certified -t <br /> Plant Location I _ <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> �I <br /> r . i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Sap Joaquin County <br /> ordinances, state laws, and rule ,an regulations off thhee San Joaquin Local Health District. 1�U <br /> APPLICANT'S SIGNATURE X <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 Rece' y January 31 El July 1 &Received By July 31 <br /> -- REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE 3 DATE MITTED 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 Mailed Deli red <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SE $ 1601 E.HAZELTON AVE.,P.O-Box 2009 ST CKTON,CA 95201 <br />