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Applications Will Be Processed When Submitted Properly Completed. Be SureTo SignTneAPPncauvn. <br /> 11 .1 z1!?"- APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) $EPTAGE <br /> 1411 ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicatio r y ma airy usin ss' the jurisdictional area of the San uin a4 Health Distri <br /> Address <br /> rn Business Nam DBA) <br /> Owner G f Address <br /> Jdc7 C/ <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No._s; <br /> a Business Telephone No. <br /> dc <br /> Contractor Licence No. Z Titlew x"" Date .5-Applicants Name (Print) G <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 <br /> Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No, <br /> CAL. License No. <br /> eights & Measures No. <br /> Capacity Gal.,Wi <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chem ical,Toilets Stored <br />` 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S. or R.C.E. Name .: <br /> Test Date/Time <br /> f Test Location <br /> 4. CYSANITATION PERMIT <br /> Job Address/ cationill p' <br /> Address <br /> Owner ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPO L ©.CCHING FIELD1PAARGE PIT 11 OTHER <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) —Q <br /> 6_ Cl PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I <br /> r�L <br /> Ir <br /> I hereby certify that I havehis aktion and that the work will be done in accordance with San Joaquin County . <br /> ordinances, state la6aZ <br /> gula an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee 1s DUB: ❑ ANNUALLY PER UNIT 0 PER SITE EACH ❑ January 1 &Received By January 31 ❑ July 1 R Received lMITuly 31 <br /> BILLING REMITTANCE AMOUNT DUE CHECKED A � <br /> BASE EXPLANATION DATE DATE REMITTED AM,O<U <br /> F FEE a <br /> I[ LESS <br /> PRORATION <br /> PLUS �^ <br /> PENALTY <br /> OTHER <br /> OTHER <br /> IReceipt No. Permit No Issuance Date Mailed Delivered <br /> Received by Date <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16D1 E.HAZELTON AVE.,Po OTI ON,CA 95201 <br />