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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Si -The_Applic_ation.­ 5� <br /> ' (For Non-Transferable;Revocable;and Suspendable) <br /> SEATAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> ApplicaY s hereby madeto carry usinesshe jurisdictional area of ' n l loaqui o 1 alth D' i <br /> Business Name DIIifBA <br /> ato ( 4p ) Address <br /> Owner__. 9 Address <br /> U Firm Partners, <br /> Addresses and hon mb r W <br /> a. Business Teleph ohe No.. _ Emergency Telephone No. <br /> Contractor Licenc No. <br /> L Applicants Name oI E.1.d Title _ Date <br /> n: <br /> Please check Applicable Category(1-7),and Fill in the Required Information :; a n <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) . �� <br /> For July 1, June 30,•19 Disposal Sites <br /> Description(MakeN` r., Color) <br /> Serial No. CAL. License N . -..._.No.. <br /> CAL. License Renewal . <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address �' � ar `'ti'•y <br /> 2. 11 PUMPER YARD }r . <br /> For July 1,_...._�^ June 30, 19 <br /> No. of Vehicles Stored f r^ i a �` ate; <br /> No. of Chemical Tip ilets Stored '�6 M ti: *� i' ..• ? �"�j ` <br /> 3. ❑ PERCOLATION TEST t `• @ <br /> R.S. or R.C.E. Na meY�af ` ' I x € �� <br /> R S.or li.G,E. No. <br /> ,gyp 11 % j 1 f <br /> Test Location 9` Test safe/T <br /> 4. ❑ SANITATION PERMIT f•J� i 'y �+ � s. 1 •��� f <br /> Job Add CAL ion <br /> Owner Address <br /> ❑ IC TANK CESSPOOL ` ��,, LEACHING FIELD �❑,., SEEPAGE PIT ;❑ PACKAdE-PLANT <br /> PERMANENT' ❑ TEMPORARY i'9-1 EW &<PAIR ❑ OtHER I <br /> 5. ❑ CHEMICAL TOILETS 'For.July 1, <br /> Type Construction Disposat:Site: <br /> No. of Units �d Equipment Storage/CleaningaC <br /> -Lation(s) i f <br /> 6. 11PACKAGE TREATMENT PLANT ibr'July i;- 4. <br /> Ju30, <br /> Operator Name r `" ` '�= �` } �+ i Whdre Certified 1 <br /> t <br /> Plant Location NM _ � �' 9 �'�• <br /> Plant Capacity A No. Units Served 3 <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 GLEANING, Chemicals Used/Amount/Mo. i <br /> I hereb. certify that I have <br /> y y p p thi -application and that ill be done in accordance with San Joaquin County <br /> ordinances, state laws, and s d regulations of the u' o I H alth District. <br /> 'APPLICANT'S SIGNATURE X <br /> FOR D A NT USE' Y,=` <br /> v <br /> Fee Is Due: © ANNUALLY El 'U <br /> PERNIT ❑ PER SITE ❑ EACH ElJanuary 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 II I <br /> PRORATION <br /> PLUG <br /> PENALTY1v I— <br /> OTHER <br /> OTHER qV <br /> YYYY x4 <br /> y S, <br /> Received by �II Date. �•�,} 1,y�Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—IIRETURN ALL COPIESTO; ENVIRONMENTAL HEALTH PERMIT/SERVICES '1601 E.HAZELTON AYE.,P.O.Boni 2009 STOCKTON,CA 95201 <br />