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(For Non-Transferable, Revocable, and Suspendable) <br /> S: ENVIRONMENTAL HEALTH PERMITTAGE <br /> LIQUID WASTE <br /> Application reby madeAqi7yry on businep in the jurisdictional area of the San Joaquin Local Heaph District <br /> Jsiness Name (D ) 0 _ _ Address <br /> . a <br /> `caner Address <br /> =Firm Partners, A dred sses and Telephone Numbers —. � �� _/ c <br /> usiness Telephone No. Emergency Telephone NO. <br /> ontractor Licence No. 3 d 3 , r <br /> E ls� e-f c A— _ <br /> -applicants Name {Print} Title X77. Date <br /> Please check Applicable Category(1-7) and Fill in the Required Information <br /> F ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> or July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> F,;erial No. CAL. License No. CAL. Liccnse Renewal No. <br /> apacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> Jo. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> F ❑ PERCOLATION TEST <br /> -.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Loc " n Test Date/Time <br /> SANITATION PERMIT z <br /> ob Address/ cation D D 4 C ✓r <br /> vwne L'� Address D �f <br /> t��SEPTIC TANK 11 CESSPOOL BLEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT 0 <br /> F D PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER Q <br /> r i. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 a <br /> Type Construction Disposal Site <br /> o. of Units Equipment Storage/Cleaning Location{s} <br /> F. <br /> ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> • r <br /> Operator Name Where Certified <br /> Plant Location <br /> 1lant Capacity No. Units Served <br /> 7-. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. FL, ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> L +' I hereby certify that I have prepared this application and that the work will be done.in accordance with San Joaquin County <br /> ordinances, state laws, and rut s a e latians of the San Joaquin ocal eaIt istrict. <br /> APPLIGANT'S SIGNATURE X <br /> i <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> 4 <br /> z <br /> Fee Is Due, ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> B1ArSE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED I <br /> y � AMOUNT <br /> FEE <br /> LESS 6 <br /> PRORATION <br /> PLUS <br /> s PENALTY r <br /> OTHER <br /> OTHER <br /> Received by Date Receipt Na Permit Ne. ssuance IDate Mailed Delivered I <br /> I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.D.Boz 2009 STOCKTON,CA 96201 <br /> � e, <br /> I <br />