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I Applications`Will Be Processed When Submitted Properly Completed. BeSureTo Sign ineAppliCauon. <br /> - APPLICATIONS <br /> (For Non-Transferable, Revocable,and Suspendabie) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> lApplication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health D' trict <br /> FBusiness Name DBA} TC Address <br /> zz Owner <br /> / f Address <br /> Firm Partners Addresses and Telephone Numbers Z3.- Z <br /> IL Z Emergency Telephone No. z�' +�7 2 <br /> M Business Telephone No. <br /> Contractor Licence No. l +I <br /> L Applicants Name (Print) gip= Title Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br />}~ 1. ❑ PUMPER VEHICLE PERMIT`REGISTRATION (FOR EACH VEHICLE)11 <br /> I For July 1, June 30, 191 <br /> Disposal Sites <br /> I� <br /> Description(Make/Yr., Color) I <br /> Serial No. CAL. License No. GAL. Lic se Renewal No. <br /> Capacity t Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemileal Toilets Stared I� <br /> -�I�- . <br /> 3. r❑'PERCOLATI8�_'_WTES7� I� <br /> R.S.oi'R.C.E�l Name -r R.S. or R.C.E. No. <br /> .q. <br /> '04", <br /> t LocSation <br /> !'� Test Date/Tim <br /> 4.. ❑ ANITATION PERMIT )� G y <br /> C_ /V T Z <br /> ob Address/Location ���� -- <br /> ess <br /> ❑ CESSPOOL LEACHING 13D SEEPAGE `'1'�PACKAGE PLANT <br /> F <br /> SEPTIC�ANK A ....� . .OM,�, ­11111,F I <br /> PERMANENT 11TEMPORARY NW ❑ REPAIR � QTiER " <br /> S. ❑ CHEMICAL Ta1LETS For July 1, -June , 0, 19 f � � <br /> Type Consirluc 'on gsposal Site - <br /> No. of Uri its'I IL Equipl�t Storage/Cleaning Location( <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 193e,WM�' <br /> ( Operator Name here ertified"- <br /> q• ' !+ <br /> ,r Plant Location IL <br /> rh <br /> Plant Capacity I No. Units Served + - <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑IiLess Than 1,000 SgIlFt., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> li hereby certify that I have prepared this application,and that the work will be done in accordance with San Joaquin County <br /> } Ordinances, state law` r es and re la . ohe San Joaquin Local Health District. <br /> APPLICANT'S SIGNA E <br /> u <br /> .0 y - y /� <br /> Zz <br /> I ' FOR DEPARTMENT USE ONLY <br /> 9 <br /> Fee IS Due: ❑ ANNUALLY PER UNIT PER SITE EACH EI January 1 &Received By January 31 0 July 7 &ReceiveRdEMIITuly 31 <br /> E i� BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> 4 <br /> FEE I1: O / <br /> LESS I <br /> F PRORATION <br /> PLUSii <br /> PENALTY <br /> DTHERI�I w / ' —µ2 ? " <br /> OTHER II� <br /> ' Q <br /> 1 -79 1.3 3 _-71-9 7 1 1 l i <br /> Date Receipt No. Permit No <br /> issuance�nce Date Mailed Delivered <br /> 3 Received by ') <br /> .APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 ON,CA 95261 ,„ <br />