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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Translerable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> L LIQUID WASTE <br /> r Appiicatio hereby made to car on busin In th risdictional area of th San Joa in L AT `lth istr t <br /> y Business Name (DBA)T_ �tlST C'• Address <br /> i Owner Address _. <br /> 9 <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. _ <br /> a Applicants Name (Printi, Title �/f�E7irie Date l ` <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 /> Serial No. CAL. License No. - .._.._ CAL.License Renewal No. : <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 <br /> No of Chemical Toilets Storech <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT /J <br /> Job Addre ocation <br /> Owner o Address W-3 tel _ <br /> SEPTIC TANK ❑ CESSPOOL W EACHING FIELD RSEEPAGE PIT ❑ PACKAGE PLANT <br /> W-IIE-RMANENT ❑ TEMPORARY R"VIEW ❑ REPAIR ❑ OTHER iiC)'O <br /> 5. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 �� p{ <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <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 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. _ <br /> :orleown® r: ' sed agent'SsIFnalurerertifie�tfie!otiawing:'I��rti,y{ dtinthepe"`nrl�n-'t t?h£wafk`orwNch,,,isp­-I 56Sve _''dll ;'.1 sir_"ill) <br /> .:tl,m c!>r,E d`• i3 y,.,;,1 i:2 SUJ eCt iU tVr}rK man's COfnpZ?1ea316R i~Of Calf affild.• - _ _ -. ., . <br /> Sus:-corimriinp. sit,a2z. erti se a -c,.}cuulr.;;: t ertify'hat in the perfloriran.e of 1'ice wari'i 1L,; i,h 7 ...,s, i',. ,'.• <br /> Ji iL WOrk;idlla CO?fcri5'vit'.�iE SUt �311:d -. <br /> I here15y certify that I have ep d this appllcati that the work will be done in accordande with San Joaquin County <br /> ordinances, state law ul and regulatio S In aqui oCal Health District.,y <br /> APPLICANT'S SI�ALA�}WE <br /> FOR DEPARTMENT USE ONLY— <br /> Fee <br /> NLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 8,Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION RMDUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEELAS <br /> LESS <br /> PRORATIONpf <br /> -- <br /> PLUS <br /> PENALTY - _5 - � -�-�/_°�� �'C � W... �.I%' .•i <br /> OTHER <br /> OTHER -- <br /> i [� <br /> Received by Date Receipt No - Permilo Y' ' I Iss-a r � <br /> ua a Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAiEL AVE•,P.O.Box 2009 STOCKTON,CA 95201 <br /> �3 <br />