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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) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Application is reby made to a on business in thNuris tional area of the Sa Joaq in Local Health Distri <br /> HBusiness Name (DB Address 4, <br /> z Owner Address <br /> 4 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. `� `� Emergency Telephone No. <br /> Contractor Licence No. T Z <br /> Applicants Name (Print) Title Date <br /> 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. Li=-,se Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD N <br /> For July 1, June 30, 19 CA i <br /> No. of Vehicles Stored JI <br /> No. of Chemical Toilets Stored CC <br /> 3. ❑ PERCOLATION TEST Q <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test L�tion Test Date/Time <br /> 4. 16SANITATION PERMIT t <br /> Job Address/Loc 57V'r Ic-Wet k6' 119 <br /> Owwddress s"C" �l EJ—AP— <br /> LAS, S DTIC TANK ❑ CESSPOOL 'CHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> Ld PERMANENT ❑ TEMPORARY r'-NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 119 <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 /> If 7. ❑ LAUNDRY For July 1, -June 30, 19 "w <br /> k SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul d regulations of the <br /> San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July l &Received By July 31 <br /> REMIT <br /> i BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE - CHECKED <br /> DATE DATE REMITTFL) AMOUNT <br /> �r <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> I _ 'J I <br /> F - Received by - Date ReceVpt No- erm t No. Issuance ate Mailed a red <br /> [ APPLICANT—RETURN ALL COPIES TO: ,EENVIRO ME T L HEALTH PER T/S RVICES/ 1601 E.HAZELTON AY .O.Box 20009�STOCKT N,CA 9 01 �7 <br />