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v Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> rw ^` APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEP7AGE <br /> LIQUID WASTE <br /> Application i herebyrade to carry business in the jurisdictional area of the gg$g=Joain Local Hea th District �. 1 <br /> Business Name (DBA) : �"� Address- f3�111 <br /> z Owner �=� Address 1 46Z 09-6 ,5'1rZ 19 <br /> a - <br /> 9 Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. �� �_ Emergency Telephone No. <br /> Contractor Licence No. _ <br /> a U jam' Date. <br /> L Applicants Name (Print) Title <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) P <br /> Serial No. CAL. License No. CAL. Liz;.,-se Renewal No. <br /> I Capacity Gal., Weights R 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 Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> r. <br /> Test Location Test Date/Time ^ <br /> 4. ❑ SANITATION PERMITaDo' �� <br /> Job Address/Location � r4 <br />' Owner <br /> -, � <br /> ! SEPTIGTANK ❑ CESSPOOL 12<EACHING FIELD ,❑ SSE�EE--PAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT 13 TEMPORARY 13NEW JEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction . Disposal Sitet <br /> N No. of Units Equipment Storage/Cleaning Location(s) <br />'+ 6, ❑ PACKAGE TREATMENT PLANT For July 1,-ti June 30, 19 <br /> Operator Name <br /> 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. F <br /> I hereby certify that I have prepared this applicion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulatio otj_hj�.San Joaqu Lo _I Health district. 4 J F <br /> _, !alt <br /> APPLICANT'S•SIGNATURE.X <br />} r FOR DIE .- T ENTUSE ONLY w- �-- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ CH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLI REMITTANCE -$ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> D E DATE REMITTED AMOUNT <br /> FEE ' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY i <br /> " OTHER <br /> ,rt <br /> QTHER <br /> -10 5 • 1 7 <br /> Received by Date Receipt No. Permit No. Iss ante ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES ,1601 E.HAZELTON AVE.,P.O.Box 2049 STOCKTON,CA 95201 <br /> P ' <br />