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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign'The Application. r
<br /> APPLICATION f �4'
<br /> (For Non-Transferable, Revocable, and Suspendable) r ,1� y, SrQT-AG 61
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Appiicat' n is her.(W2jy made to carry on business in the jurisdictional area of San oaquin Local Health District
<br /> 1n Business Name (DBA) • r 1-1Address S•
<br /> z Owner Address
<br /> a
<br /> J Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No. g6V7 Emergency Telephone No.
<br /> Contractor Licence No. �-
<br /> L Applicants Name (Print) Title"A h&r,C—'12. Date
<br /> Please check Applicable Category (1-7)and Fill in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C
<br /> For July 1, June 30, 19 Disposal Sites (�]
<br /> Description(Make/Yr., Color)
<br /> Serial No. CAL. S-e 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 to
<br /> No.-of'Vehicles Stored
<br /> No. of Chemical Toilets Stored
<br /> 3. ❑ PFrRCOLATION TEST`•4 - 1» -- - _ ---• —}
<br /> R.S. or R'.C.E. Name. s R.S. or R.C.E. No.
<br /> v
<br /> Test L cation c s ' Test Date/Time
<br /> 4. SANITATIOgPER t�
<br /> Job Address/Location � SO IRP +� 7C
<br /> O ner Address`
<br /> SEPTIC TANK ❑ CES y'O�L EACHING FIELD ❑ SEEPAGE PIT 11 PACKAGE PLANT r�
<br /> u •.
<br /> ;9-PERMANENT ❑ TEMPORARY XNEW; t y".: sl YREPAIR ❑ OTHER
<br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 I
<br /> Type Cons;rdbton : t.,.Disposal Site
<br /> No. of Units U x `+ t r•EquipmenfStorage/Cieaning'Location(s)
<br /> ti
<br /> 6. 0 PACKAGE TREATMENT PLANT For July 1�1 June 30, 19
<br /> Operator Name Where Certified f
<br /> ,.,
<br /> Plant Lo4tion r
<br /> Plant Capacity -! No, Units Served '
<br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 s ) r
<br /> SIZE: ❑ Less ThanRj,pOfl Sq. Ft-7 0 More Than 1,00Q Sq. Ft.
<br /> 0 DRY CLEANING, Chemicals Used/Amount/Mo. ! t #
<br /> I' 1�11sreo>•.:1E:rorti:es�aav[ta�a 'ssi�, arrsrar..?�aft Wt'�•T�<::•.:r`y-s.a ',,A,ntfl ^��dC1 r?r, .,rEt�"�;a:5r!:�+TI'+1E�;^htfii �r-nt ,,I',aii j p!n _
<br /> �, rn:, - sp.. i, siss�Jed.'. .ui., e^,,1,�yanype-.
<br /> fist 5:iG11 itl$nnit 3S t0 'E -
<br /> Contractor's hiring or voib-con.re;t,r_l sig�snture ut+rl fres 'Illy fGh4wirg: 'I _EINly#.h it'.r::he peril riT:,1:1 i;i:!te Wr ri:Fnr #idi t:,i.,ncrn':t Is issued,l Shall
<br /> employ persons subinot to w0i<rrlan s ccmpansaticrr t3.Ys of Callfotric.."
<br /> I hereby certify that I hav prepared this application and that the work will be done in accordanie��v th San Joaquin County
<br /> ordinances, state laws nes and regu ns of the n Joa u' cal Health District. f t
<br /> APPLICANT'S SIGNATURE X ,
<br /> FOR DEPARTMENT USE ONLY
<br /> t
<br /> Feb Is Due: ❑ ANNUALLY ❑ PERSUNIT ❑ PER SITE ❑ EACH ❑ January 1 &Receive y J ❑ July 1 &Received By July 31
<br /> — '- REMIT
<br /> BILLING REMITTANCE
<br /> BASE EXPLANATION .AMOUNT DUE CHECKED
<br /> DATE DATE M ED AMOUNT
<br /> I
<br /> FEE
<br /> LESS
<br /> PRORATION
<br /> PLUS 1'.
<br /> PENALTY s
<br /> OTHER t r l
<br /> f ,
<br /> Received by Date i Receipt Na .� 3 Permit No.. —i L• - 1s uance,pate _ Maiied Delivered k�
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 1601 E.RAZELTON AVE.,P.O.Boa 2009 5TOCKTON,CA 9°'
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