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e ouir <br /> ...r•_ - 4. v.M.. <br /> _ <br /> Applications WiR Be Processed When Submitted Properly omp <br /> APPLICATION SEP7AGE <br /> (For Non-Transferable,Revacable,'and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is ereby made to carry on business in the;jurisdictional area of the 5�Joaquin 1t�District r£ . <br /> aE Address 1, <br /> Business Name(D8A) crier <br /> Address - <br /> aOwner S _ 4 <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> a Bu slness-Telephone No. <br /> TC/4/iy :{Date I <br /> 1 Contractor Licence No itleo , <br /> ^tea { r r J <br /> Applicants Name (Print) uired Information ,�fit : <br /> F <br /> Please check Applicable Category 0-T)and Fill in-the Req , , <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) e <br /> Disposal Sites <br /> For July 1, = -June 30;'19 <br /> r ,y <br /> Description(Make/Yr., Color) CAL. License Renewal <br /> No. <br /> `I CAL. License No. <br /> Serial No. <br /> Gal.,Weights&Measures No. <br /> Capacity <br /> � <br /> Equipment Parking Address <br /> 2• ❑ PUMPER YARD !' <br /> 'For July 1, June 3Q, 19 <br /> No. of Vehicles Stored <br /> J_ <br /> No. of Chemical Toilets Stored <br /> g. ❑ PERCOLATION TEST R.Si or R�C.E. No. ' <br /> R.S.or R.C.E. Name <br /> Test Date/Ti4 ' �` '`y`:_ <br /> me` t` <br /> Test Location <br /> rIr� t <br /> '':kA, L.# 1 + <br /> q, tL5AN17ATION PERMIT l/ 1�, r A. i <br />! Job Address/Location - + i' <br /> v Address 1 }' <br /> Owner ❑ PACKAGE PLANT t ---� <br /> ❑ LEACHING FIELDSE7=PAGE PIT <br /> ❑ SEPTIC TANK ❑ CESSPOOL El <br /> NZ REPAIR 11 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY i <br /> t <br /> 5. ❑ CHEMICALTOILE75 For July 1;-June 30. 1Disposal Site _ l <br /> I Type Construction ' <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> # t � <br /> {, Q PACKAGE TREATMENT PLANT !For July 1, -June 30, 19 Where Certified <br /> 'Operator Name i 1 <br /> Plant Location , x. r No. Units Served <br /> Plant Capacity i <br /> 7. ❑ LAUNDRY For July 1, -June 3fl.❑ More Than 1,400 Sq. Ft, <br /> SIZE: 11Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. . is <br /> Homo ownerorficeitsgdage^rt'ssignmturecerrlbesothef40110% S �lcfrCsi e3*irgtheperro•maneIc�th�icarkic �!`hellvorrklortwh+ichihislpemitiisissu d,Ishali person <br /> in such manner as in become subject to Wor l certi:y ihe,., p _ <br /> Contractor's Firing or sub-contracting s,g�tit <br /> tars cEr:Ete ` � tullmvsesg: <br /> t employ persons subject to warl;man s con;pensatlon lavas of Calllarnia." <br /> r " 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, rule and r afions of the San Joaquin Local Health District. <br /> 1 APPLICANT'S SIGNATUREX~ - <br /> FOR DEPARTMENT USE ONLY 'f <br /> ed By July <br /> I REMIT <br /> } Fee I5 DUE: ❑ ANNUALLY ❑ <br /> PER UNIT ❑ PER SITE ❑ EACH <br /> T] Jan 1 &Received By January 31AM0 ❑TJDUEuly t X Rece�CHEMIT 31 .. <br /> BILLING REM ITTRNCE REMITTED OUNT <br /> 1 BASE EXPLANATION DATE DATE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER �v <br /> OTHER <br /> C `[�� 2� Issuance Date Mired Delivered, l* <br /> CA 95201- <br /> Receipt No. i w Permit No - - <br /> Re eive by D e 1601 E:HAZELTON AVE.,P.O.Box 2909 STOCKTON, , <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES <br />