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Applications Will Be Processed When Submitted Properly Completed. BeSureTo sign <br /> II APPLICATION <br /> ji (For Non-Transferable, Revocable,and Suspendable) SEi°TAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i �erebmade t car on�bines�Address <br /> uri fictional area of:theaanJoa uin Local Health DistricAddress <br /> NBusiness Name (D ) <br /> z Owner <br /> a ,, <br /> Firm Partners, Addresses a d Telephone Numbers Emergency Telephone No. <br /> Il a Business Telephone No. <br /> Contractor Licence No. <br /> Title Date <br /> Applicants Name(Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Inf ation <br /> 1, •❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, + June 30, 19 Disposal Sites <br /> Description(Make/Yr:, Color) CAL. License Renewal No. <br /> Serial No. ` ' CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address ti <br /> 2. 0,PUMPER YARD ; <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> T 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name 'I � <br /> T �t Test Date/Time <br /> Test Location <br /> It, <br /> 4. ❑ SANITATION PERMIT'- id <br /> Job Addre /Location II Z 5� �C/ A <br /> f Address <br /> Owper ,,,� 1 T ❑ PACKAGE PLANT Q� <br /> C��WT C ANI ❑ CESSPOOL I,l,,d,'L GHING FIELD REPAIR <br /> ❑ OTHER I <br /> D"PERMANENT_ ❑ TEMPORARY L+ EW (� <br /> 5. ❑ CHEMICAL•TOILE7S For July 1, -June 30, 19 <br /> Type Construction---- !I ilk `' � Disposal Site <br /> No. of Units IM �Ivl 4 Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 , <br /> Where Certif ted- � <br /> t Operator Name <br /> Ir Plant Location <br /> No. Units Served �, T <br /> Plant Capacity Y <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: 13 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this application and thatat theill be- n Local will <br /> be r District. <br /> ordinances, state laws, and rules and re ations of the.S aq <br /> l APPLICANT'S SIGNATURE X <br /> it _ � �.... . _ ...._ �.. __.�.. ,.«._--•, <br /> !I 1 FOR DEPARTMENT USE ONLY <br /> l il ❑ Januar 1 &Received By January 31 - ❑ )uty 1 &Received By July 31 <br /> - Fee is Due: ❑ ANNUALLY - ❑ PER UNIT ❑ PER SITE ❑ EACH _ y _ REMIT `r <br /> k BILLING REMITTANCE $ AMOUNT DUE CHECKE <br /> - BASE EXPLANATION DATE DATE REMITTED AMO'N <br /> kli ep Q <br /> FEE <br /> L5 c Q <br /> f D` <br /> LESS O <br /> PRORATION <br /> PLUS <br /> f PENALTY <br /> F OTHER <br /> OTHER li rk <br /> 03�7` T <br /> i 1 4 <br /> ;r Issu nce ate Mailed Delivered <br /> r Date Receipt No. Permit No. <br /> Received by = ' <br /> APPLICANT—:RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ...1601-E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON;CAE1r �� <br /> 61 G,4&,04_ b <br />