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, <br /> ME- <br /> i ` �r ' a b ���a�s���?5�.� �r!ta�F::�rr,a��'a.:i�: .,�.;�''�.^:`.���L"�,. � _r? • .i.. <br /> LIQUID WASTE <br /> Application is hereby ma e to carry on busin sin th ju isdictional area of the San Joaquin nLocat Health District <br /> rn Business Name (DBA) C TMA <br /> -! _ f= L �' — Address J <br /> z Owner r' Address <br /> a <br /> J <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. Emergency Telephone No. M <br /> Contractor Licence No. <br /> L Applicants Name (Print) � L Title ate <br /> Please check Applicable Category (1-7)and Fill in the Required Information F <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. Lic;.nse Ren6 al 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 Stored <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 PEMI� <br /> Job Address/Location,, <br /> Owner G !�SAddress <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD (SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY LNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> ..1 <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 /> I• <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> -- SI'ZE: 0. Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft: �r <br /> ._r--❑ .DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Home owneror liconsedage"t's signaturecertifies the following:"1 certify that in the performance of the work for which this permit is issued.I shall not employanyperson <br /> In such manner as to become subject to workman's comper,zation laws of California" <br /> Contractor's hiring or sub-contracting signal:,ro car<_r;ns the "{allowing: "I certify that in the performance of the work for which this permit is issued,i shall <br /> employ persons subject to workman's compensatioc,:aws of L_Jfornia." <br /> I hereby certifyI have prepared tis application d that the work will be done in accordance with San Joaquin County <br /> ordinances, sta laws, d rules nd r ulati s o th an J u ocaE Health District. 1 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH -- ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANC $ <br /> REMIT <br /> BASE- EXPLANATION DATE DAT MITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS _ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No! Issuance!Date, ' 'Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bots 2009 STOCKTON,CA 95201 <br />