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f 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 ./ ' SFPTAGE <br /> LIQUID WASTE , <br /> Application is hereby made to carry on business in the Jurisdictional area of the San Joaquin Local Health District <br /> F Business Name DBA �TRaQ L W �[�AD = 'PQM` Q_�� 9SZa ! <br /> ( ) 4, lyC.. _Address :P>in <br /> )4� <br /> c Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. _ 4—<X_0-7 _- Emergency Telephone No.. <br /> Contractor Licence No. ZS4 43 �l <br /> C Applicants Name(Pant) Title EST')&}AT Ql4? Date S—Zi <br /> ( Please check Applicable Category(1-7)anh FIII In the Required Information 6- <br /> i 1. ❑ PUMPER VEHICLE PERMIT REGIS+RATION (FOR EACH VEHICLE) <br /> E For July 1, June 30, 19 1 Disposal Sites <br /> Description (Make/Yr., Color) <br /> ,Serial No. _CAL. License No. CAL. License Renewal No. <br /> Capacity _ Gal., ights& 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 /> "i 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time j <br /> 4. ErSANITATION PERMIT <br /> Job Address/Location WrcJry 7—IG 0 !5'`T� <br /> Owner Address S,4"F; _ <br /> 11SEPTIC TANK ❑ CESSPOOL El"LEACHING IELD C3 SEEPAGE PIT ❑ PACKAGE PLANT <br /> CRIPERMANENT ❑ TEMPORARY ❑ NEW B REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 (}J <br /> Type Construction Disposal Site <br /> r_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 t <br /> SIZE: ❑ Less Than 1,000 Sq. FL, Q More Than 1,000 Sq.-Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.. <br /> I hereby certify that I have prepared this ap licatio that t work will be done in accordance with San Joaquin County <br /> ordinances, state law s and reg IonA0e,,11an J qui Lo al Health District. I <br /> APPLICANT'S SIGNATURE • -_ 71 <br /> 1 ' FOR DEPARTMENT USE ONLY J <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT _ U PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> " BILLING REMITTANCE $ REMIT <br /> i <br /> BASF EXPLANATION AMOUNT DUE CHECKED <br /> GATE GATE REMITTED AMOUNT t <br /> A , FEE} � i f C — <br /> `46 <br /> r + <br /> PRO <br /> - <br /> PRORATION s , <br /> -------------------------- <br /> .PLUS- <br /> PENALTY <br /> LUS-PENALTY �Q-f <br /> OT14ER <br /> OTHER <br /> -__ l�sl 1I <br /> Received by Date •., 1 Receipt No. P&mil No. + Iss ante D MailedDelivered '! <br /> _APPLICANT—RETURN ALL COPIES TO!, ENVIRONMENTAL HEALTH PERMIT/SERVICES ` 1601 E.HAZELTO .O.Boa 2009 STOCKTON,CA 05201 �'L/, <br />