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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION WMINE©I (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon busin m the jurS ctional area of the an Joa uin Lo I He (th District <br /> FBusiness Name (DBA) _F LT ��� �L�\C)tpdd ress - t— 1G�V��l� <br /> Owner L t (_ IL-_ Address T <br /> Firm Partners, Addresses anGd TeeIII ne Numbers <br /> q. Business Telephone No. f .S fc 1 I Emergency Telephone.No. <br /> JContractor Licence No. <br /> 4 Applicants Name (Print) L y\vs, \L�`�, � Title <br /> Please check Applicable Category (1-7)and Fill In the Required Informatlon ) <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites .,1 <br /> Description(Make/Yr., Color) Q� <br /> Serial No. CAL. License No. CAL. License Renewal No. 11 <br /> 'Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address- _ <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored W <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 Location T�ssJ{.�a fri e <br /> 4. ❑ SANITATION PER <br /> I <br /> Job Address/Location <br /> Owner _ Address <br /> SEPTIC TANK ❑ CESSPOOL EACHING FIELD EPAGE PIT 13PACKAGE PLANT !� <br /> PERMANENT ❑ TEMPORARY W REPAIR ❑ OTHER b <br /> S. 11 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> In <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) r <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 So. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home such <br /> man ror Ucensedme suj ssan ,•rrsr ru{, yn leuw+rte 1 .^rtfly tl .l nh:e prr;Cm,1Pce of the wc`,rerwhirl,this permit is issued.I shall npl empfnv any perscB <br /> ov,enner aicenses to pme subs icn is":c n+c1 I„ t fagie t ..3 <br /> Contractor's hiring or aubtontra nM. •nd r. ity;en n,: -I grri� �hel.rt the pertC";- . . . r- - ',,h3ll <br /> employ persons subject to y: ;h r .c 1 In,a:,s Ullo o .4,.- f q� <br /> hereby certify th have prepared t 's application nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, rules an t San Jo quin ocal Health District. rC� <br /> APPLICANT'S SIGNATUR <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 S Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �yy AMOUNT <br /> FEE Is <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY �' U <br /> OTHER <br /> OTHER Y <br /> � lodlo 7 <br /> Received by - - - - -- ffi— -"Receipt No. — -- - -Permit No. Issuance Date Brad - - Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAIELTON AVE., .O.Box 2009 STOCKTON,CA 95201 <br />