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�.— Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION C) � IS�P�� �6 <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica s hereb ade to car busine�tr�.' isdictional area of the San Joaq- ' o�T th tris -� <br /> y ,Name (DBA ��f �> �y` �' Address ` <br /> z Owner Address <br /> a <br /> Firm Partners, AddresseAandhokmb5er7s <br /> ne NuEmergency Telephone No.aBusiness Telephone NoContractor Licence No.LApplicants Name (PrintTitle Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1,_June.30, 19 - Disposal Sites <br /> Description Make/Yr., Color) ,„ ---- <br /> p { Na._ � CAL. License Renewal <br /> Serial No. CAL. License No. <br /> Capacity daL, Weights & Measures Nor <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD <br /> For Jul 1, June 30, 19 <br /> No. of Vehicles StoredNo. of Chemical Toilets Stored <br /> 1 <br /> 3. ❑ -PERCOLATION TEST �• <br /> or R.C.E. No.'k>. <br /> R.S. or R Git. Name <br /> "I t ! } ( Test Date/Time <br /> Test Location <br /> 4. ❑ SANITAi.ION PER --� <br /> f t l <br /> Job Addr ocatio'n t <br /> Ow <br /> -� Address ��i/a'f't - •--�:M <br /> ❑ SEPTIC TANK'— CESSPOOL• '�CEAC!41NG-FIEL15 -L�^"EEPAGE PIT ❑ PACKAGE PLANT <br /> +_ #` ry ✓ ❑ OTHER j <br /> W''�RMANENT ❑ ?EMOORARY �IGEW B'REPAIR" r� . <br /> 5. ❑ CHEM ICAL TOILETS For July 1,�-June 3�/"1.9 <br /> .' c!i <br /> ` :• Disposal Site <br /> Type Construction �. .tea: <br /> LI' Equipment Storage/Cleaning Location{s) + <br /> No. of Units , r <br /> I' " <br /> 6. ❑ PACKAGE TREATMENT PLANT For-July 1, -{June 30, 19 <br /> WP1ere Certified <br /> I Operator Name' <br /> Plant Location <br /> r 4 r� ...� 1Vo ifs Served { ,. ; <br /> E Plant Capacity _ �,... <br /> f 7. ❑ LAUNDRY For July 1,-Junej30, 19 ` <br /> 4 SIZE: ❑ Less Than- dOO£Sq. Ft., ❑ More Than•1,040 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo..; <br /> Romeo+nrnerorlicensedagerft's,>rtgrral�'tie�erlfibf,M+r'#flil°y""'E3' 'i'teriifytha'itthtperlorma ceoftheworkforwhichthispermitisissuttf;istlal�natetnpoyanypersa <br /> in,stichrmanner as to becomf 64bj�to arkmad5 COTQBnSatiGT1 laws of Gatifor 11a." ` <br /> Contre�t4`r•s 1t kir+A/at;,aubs-con'rreetlf,�.-ft"aiur�,i arnfira td ei'v�'+�' '#certify t[1at in the periarrtrar+ce of tAe work for which tTtis permit is issu+d,i shall <br /> employ <br /> persons <br /> esols ett to workman's c mpet}&3tlon taws of Cant <br /> . l L <br /> l!hereb certify at L have pr a `6 i pplication/and t �, will done in accordance with San Joaquin County - ? <br /> f y _ <br /> ' ordinances, state I s, ul 'ons uln a I _ <br /> r -i:>' + ' <br /> 4 APPLICANT'S SIGNATURE <br /> a # fFOR DEPARTMENT C1SE ONLY - <br /> I <br /> Fee Is Due: ❑ ANNUALLY ❑ PE_R t1NIT____ 0,PER SITE ❑ EAG H v-=_�.❑_Januar 1 &Received By;ilanuary 31 © July 1 &ReceiveRdBy EMITuly 31 <br /> -' »-. BILLING REMITTANCE $ ,. <br /> I BASE EXPLANATION i AMOUNT DUE CHECKED , <br /> - `PATE t DATE �€ REMITTED AMOUNT <br /> FEE <br /> LESS 1r s > <br /> PRORATION <br /> PLUS i..! . ':=�l ,,.,- ,/'-r .4,r"�-• ' _-.`ti` 'L+ S <br /> PENALTY <br /> OTHER <br /> k OTHER <br /> Received`by pate Receipt No. Permit No. Issua a Date Mailed Delivered. <br /> 1601 E.-HAZEL70N AVE.,P.O.Boa 2009 -570CKTON,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />