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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Applicatiz'" <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) a <br /> SF./ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE �F <br /> Application! eby ma eAo carry on bthe j .isdictional area of the San Joaquin Loca palth District. l . <br /> Business Name A) <br /> Q i�i9 >f—r _ Address <br /> z owner $ Address / -Z <br /> 2 Firm Partners, Addresses and Telephone Numbers <br /> d Business Telephone No. 7 k LSE, SCO Emergency Telephone No. _ <br /> Contractor Licence No. �- <br /> L Applicants Name (Print) S ^ a Title Date <br /> Please check Applicable Category(1-7)andFillIn the Required Information 1 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION FOR EACH VEHICLE) h <br /> For July 1, - -. June 30, 19 _ Disposal Sites - <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored I <br /> No. of Chemical Toilets Stored t x z <br /> 3. ❑ PERCOLATION TEST r r <br /> R.S. or R.C.E.-Name R.S. or R.C.E. No. <br /> Test LoIon t Test Date/Time <br /> 4. I-7 SANITATION PERMIT i, <br /> Job Address/Location / N <br /> Owner �-- Address <br /> 11 S_IC TANK ❑ CESSPOOL LE CHING FIELD EPAGE PIT ❑ PACKAGE PLANT ti <br /> 0P` ERMANENT ❑ TEMPORARY NEWPAIR ❑ OTHER <br /> ' 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> I No. of Units Equipment Storage/Cleaning Location(s) __C;1_ v <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name ,t Where Certified <br /> Plant Location <br /> Plant Capacity f No. Units Served - <br /> 7. ❑ LAUNDRY. For July 1, -June 30,:19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft.,. More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. — <br /> Nomeawneror Hcensed agenYa signature certlfi�stha following:"l certifyy that ih ibe perfofmanre of the workforwhich tnispermttis issued,i shall not OMPloy anyperson <br /> in such manner as to become subject to wurkmari's compensati@R laws ef1catif0rrli,4 <br /> Contractor's hiring or sub-contmeting signature cerci+es the fellpwing: "1 Certify that in ft performance of the work for which this peMd is issued,I shaft <br /> employ persons subject to workmarf s compensation laws of California,.' <br /> I hereby certify that I have prepared th' plication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and tions of the San Joaquin Local Health District. <br /> n 1 <br /> APPLICANT'S SIGNATURE X <br /> J, <br /> F ,.t FOR DEPARTMENT USE ONLY ` <br /> r <br /> Fee Is Due: ❑ ANNUALLY 0 PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31, Q July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> " { + FEE <br /> f LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY{ ✓ <br /> OTHER s, <br /> OTHER *, <br /> Received by Date Receipt Not Permit No. . - Issu ce Dae ailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 19111 E-HAZ AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />