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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> A (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT - <br /> LIQUID WASTE <br /> Applicationi hereby made to carry on b siness in t e jurisdictional area of the San Joaquin Local Health Di ict <br /> a Business Name BA) _ Atldress ®��-4`/' 7G 7 } t! <br /> z Owner 4a 1 1 Address -rm� <br /> 3 Firm Partners, Addresses and Telephone Numtizrs <br /> iBusiness Telephone No. �3,12 S/C S - Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title R4___nSDate ✓ T— 7-57 <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. Licz-se 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 Stored <br /> 3. ❑ PERCOLATION TEST t <br /> R.S.or R.C.E.Name R.S. or R.C.E. No. <br /> Test LL tion Test Date/Time <br /> 4. La SANITATION PERMIT <br /> Job Address/Location —S!!. eoe <br /> Odi�Z69- Ad cesss 'V9 3/ <br /> W' PTIC TANK 13 CESSPOOL ACHING FIELD L7 SEEPAGE PIT 11 PACKAGE PLANT <br /> lY PERMANENT ❑ TEMPORARY VW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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/AmounVMo. <br /> I hereby certify that I have pre red this application and that the work will he done in accordance with San Joaquin County <br /> ordinances, state laws, and and regguulatiioonj�the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X '�• v��.e <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 8 Receive0 By January 31 .❑ July 1 a Recerve0 By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE -( s- S' r/ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0133 b <br /> 7 CA 84R - <br /> Received e1• Date Receipt No. Permit NO. Issuance Date ManeG 1 Iveff tl <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1301 E.HAZELTON AVE.,P.O.aoa 2003 „STI' TON.-C,%101 <br />