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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> 'tl '� APPLICATION <br /> (For Nan=Tiiansferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SI PTAGf <br /> LIQUID WASTE <br /> Application is reby made to arry on business in the jurisdictional area of the SarL4aquin Local Health Dist ' t <br /> HBusiness Name (D8 Addresses ?� <br /> z Owner . ... Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers P <br /> CL <br /> Business Telephone No. S�4 S" Emergency Telephone No. <br /> Contractor Licence No. y <br /> Applicants Name (Print) Titley Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 0 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial`No. I CAL. License No. CAL. License Renewal No. <br /> xCapacity ` V Gal.,We &Measures No. a' <br /> k. ,r <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 ' <br /> No. of Vehicles Stored k <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST IONT <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location ` Tosl D `/Time <br /> 4. ❑ SANITATION PERMIT .1 <br /> r �, <br /> Job Address/ ocation i ff <br /> PP <br /> r Address Q ^ t a— <br /> PESSPOOL L HING FIELD ❑ SEEPAGE IT, ❑ PACKAGE PLANT <br /> RMANENT ❑ TEMPORARY EW ❑ REPAIR f ❑ OTHER, <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 _ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -Juyne 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 "a <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. t <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> er� <br /> ; <br /> 1 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 r gulations of the S oaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> 3 <br /> k <br /> did <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNI ,❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> "I' BILLING REMITTANCE $ REMIT _ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED ' AMOUNT , <br /> FEELESS <br /> S <br /> PRORATION t S-gyp SSZ/ p+4 <br /> PLUS { <br /> PENALTY w <br /> OTHER i <br /> OTHER <br /> Received by .:, ,Date - Receipt No. Permit No. Issuance Date - Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' - 1601 E.HAZELTON AVE:,-P.O.Box 2009 STOCKTON,CA 95201. <br />