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I APPLICATION <br /> or Non-Transferable, Revocable,and Suspend StPTAGE <br /> k .r ENVIRONMENTAL HEALTH PERMIT' <br /> LIQUID WASTE O <br /> 1 area the San Joaquin Loci ealth Istrlct <br /> Application is hereby made to carry_on business in the lunsdlctlona a e of q <br /> -�� ;r <br /> .v, Business Name (DBA) r E �`_ ?' _ ;,�- `..�:". �. `moi � ... -_ . Address - - <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Business Telephone No. i;"i__ ` (, '.__:' Emergency Telephone No, <br /> Contractor Licence No. <br /> Applicants Name (Print) 1~%'s'.tii I ; r`r!.� i t Title i F..' t Date <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. License 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 <br /> R.S. or R.C.E. Name R.S. or R.C.E..N .. <br /> Test Location Test Date/Time <br /> 4. Q-SANITATION PERMIT <br /> Job Address/LocationGL'.-� <br /> L <br /> Owner - u' �J Address _ :� "t -i <br /> 13 SEPTIC TANK ❑V CESSPOOL a-CEACHING FIELD ❑-SE_EPAGE PIT ]i 13 PACKAGE PLANT <br /> ❑`PERMANENT ❑ TEMPORARY 11 NEW ED"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. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this applicatibnpnd that th work will be done in'Accordance with San Joaquin County <br /> k <br /> ordinances, state laws,�an�l s les and eguI tions 6f-0.e Sar:Joa uin;Zocal Health District. <br /> APPLICANT'S SIGNATURE Xt <br /> yS <br /> FOR DEPARTMENT USE ONLY, ,-__-- <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ Januaryl &Received By January 31 ❑ July 1 &Received By July 31 - <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEELESS <br /> PRORATION °f' <br /> PLUS <br /> PENALTY l`'j <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. 16suanke Da ail Delivered ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON—AIC;-I,.,.eo■2009 STOCKTON,CA 95201 <br />