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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Appiicauon. <br /> APPLICATION <br /> y( ion-Transferable,RevocabiL,'and Suspendabl SEPT�G r <br /> ENVIRONMENTAL HEALTH PERMIT ' <br /> LIQUID WASTE <br />' Applica is hereby made car n bu-i :'SS i h uric ctional area of the{ga Loc I H I Di trict t <br /> E Busin ame {DB Address r � � <br /> I <br /> Own r Address <br /> Firm Partners, Addresses and kph e N rs - <br /> Business,Telephone No. �y Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants'Name (Print) Title Date <br /> Please check Applicable Cate (1-7)and Fill In the equlred Information <br /> l <br /> 1. ElPUMPER VEHICLE-,-PERMIT REGISTRATION (FOR EACH VEHICLE). . <br /> For July 1, June 36, 1s Disposal Sites <br /> Descriptioh jMake/Yr Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity' ---- `;` Gal.,Weights &Measures No. ' <br /> Equipment Parking Address <br /> i <br /> 2. ❑ PUMPER YARD <br /> i <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. i{/SANITATION PERMIT ' <br /> Job Addres /Locatio <br /> O per Address <br /> E�RgPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT p 1 <br /> PERMANENT ❑ TEMPORARY 2NEW ❑ REPAIR ❑ OTHER 7" <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30.' 19 i -- - <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,1-tiJune 30, 1'9 <br /> Where Certified <br /> Operator Name , 1 <br /> Plant Location <br /> Plant Capacity No. Units Served 1 = <br /> 7. ❑ LAUNDRY For July 1, -June.30, 19 _ <br /> SIZE: 13 Less Than 1,000 Sq. Ft., ❑ More TKan.1,006 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> NameownarorRtemedagent':signatiurecenifleathefeuovding:"lcertf��yytRitl nlhCat*fiOrrillnCeofthe wolikforwhichOft p noftisIssued,Ishallnotemployanyperson <br /> . in such ntaRrler as to become'Suttjeet to vara:kman's cotnpensatio�r Izws 6f Cafiterni���-,. <br /> Contractor•m hiring w sus con�reccing,sigrsiu:e certifies the. fest wh-n. 1 certify that in the performance of the work for which this permit isissued,I shall � <br /> employ persons supject to workmali s compensation laws of calitornia" <br /> 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 Ies and regu fohs the San.Joaquin Local Health District. I <br /> APPLICANT'S SIGNATUR <br /> - i <br /> FOR DEPARTMENT USE ONLY <br /> ' Fee IS Due:bl ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT l <br /> BASE EXPLANATION BILLING REMITTANCE - $ AMOUNT DUE CHECKED J <br /> DATE DATE REMITTED AMOUNT <br /> FEE L 1 <br /> 1 LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTl ER <br /> OTHER <br /> T IQ� <br /> Received by Date Receipt No. Permit No. Iss ante Oate Maiied Delivered;'- --- — --- <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />