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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 SEETAGE <br /> LIQUID WASTE <br /> Application ip.hereby made to carry on tLusiness in the jun Ictional area of the Sa Joaqui Local Health District -452 <br /> F Business Na (DBA) =(Z- Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) . Title '-�`� Date 2� <br /> Please check Applicable Category (1-7)and Fill in the Required in ormation <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 Lica;se Renewal No. �-1 <br /> Capacity Gal., Weights & Measures No. Q <br /> Equipment Parking Address P <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 z <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No, <br /> Test L cation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Location eo <br /> Address TIC�AN �DCE�SSPL �CHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> 19 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR OTHER Slc -fes <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> 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 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 rules and regulMMC� <br /> Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee.Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE /� <br /> LESS Z <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 79 -$5a <br /> Received by Date Receipt No. Permit No Issuance Date Mailed Deliver dG <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo��9. ��C O,CA 9 <br /> 7 <br />