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Applications Will <br />Be Processed When Submitted Properly Completed. <br />Be Sure TO Sign The Application. <br />APPLICATION <br />'(For Non-Transl;ra"bli,'�Riv'o'6able, and Suspendable) <br />ENVIRONMENTAL HEALTH,PERMIT SEPTAGE <br />YF AfipiiicaLIQUID WASTE <br />-;ion is hereby made'to r n in ti <br />Business Name ( ej risdictional area of thp_�a� uin LOZITea c <br />to (DBA) <br />I- _ 'K. I _4oa Ith Di t i t <br />z owner-4.LZI Address.= It <br />Firm Partners, Add Address <br />7 Addresses and <br />IL 's 3nei Numbers <br />0. Business Telephone No. <br />-J Contractor ElcencerNo; Emergency Telephone No.,. <br />L Applicants iqame (Print}- <br />- <br />Title <br />Please check Applicable Csrt'�C91Y (1-7) and Fill in the Reate <br />1.; [:] P� quired Information <br />LIMPER VEHICLE PERMIT REGIST)tATION(FOR EACH .:.:(q <br />For July 1, June 30,-19 Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. <br />------------ CAL. License No. 1.4- <br />Capacity- GW7Veights &Measures, -No - <br />SAL. License Renewal No. <br />• Equipment Parking Address' <br />2. 0 PUMPER YARD <br />---------- <br />'- <br />For July 'l; - zlune10, <br />No. of Vehicle, Stored <br />No. of Chemical Toilets Stored <br />3. b PERCOLATION TEST <br />R.S. br R.C.E. Name <br />TestlLocation <br />TT <br />4. 13 SANITATION PETest Date/Time <br />Job Ad s/Locatlon <br />Own'er <br />"gBEPTIC TANK cESSp0O Addre s <br />PERMANENT 1-1 TEMPORARYIELO <br />_WSEEPAGE Pq <br />CHEMICAL roi" . I'll REPAIR, <br />TOILETS �W P OTHER <br />Type Construction For July June 30, ! 19 <br />7, <br />Disposal �Si4�e lz*� <br />No. of Units $�� <br />Equipment.StorageZCjearj�g Loca'tion(s), <br />6. PACKAGE TREATMENT PLANT For JuIy-_,.,1-,'--June . 30, 19 <br />Operator Name <br />Plant LocationWhere Certified------------ --- <br />Plant Capacity --- I A <br />No. Units Served <br />7. ❑ LAUNDRY For July ju-618.30"19 <br />SIZE: ❑ <br />Less Than 1 000 Sq. Ft." 0 MT <br />❑ ore Than 1,000 Sq. Ft. <br />DRY CLEANING, Chemicals. Used/Amount/ <br />Mo. <br />I hereby cetilf"hat I have <br />prepare his a, ftation <br />ordinances, s 9 laws, - nd that the . work will be done in accordance with San Joaquin County <br />r les and U 11 6 Sari <br />q ,A tical Health District. <br />APPLICANT'S SIGNATURE X <br />Fee Is Due: 13 ANNUALLY 0 ! PER UNIT <br />I : I BASE <br />----------- <br />FOR DEPARTME4TtZSE` <br />El PER SITE EACH J. <br />Oj�•x-''fi.... <br />ONLY 1 4 <br />nuary 1.&LceivedByjanu <br />EXPLANATION BILLING REMITTANCE <br />DATE DATE <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY - <br />OTHER <br />OTHER <br />4 - <br />Re eived,b <br />y Dale t <br />APPLICANT— RETURN ALL COPIES TO: ENVIRONMENTALPERMIT/SERVICES <br />enri <br />HEALTH PERMIT/S6 VICES ti <br />REMITTED <br />Issuance <br />" N D <br />E. HAZELTOX <br />- . <br />• <br />ry 31 ❑ July I & Received By July.31 <br />REMIT <br />AMOUNTIDUE CHECKED <br />AMOUNT <br />I Mailed Delivered <br />.,,x 2009 STOCKTON, CA 96201'_ <br />