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Appocauens win oe rrocesseu wnen auomneo rroperly uompieteo. oe aure ru 0r9n Inc^NNnua++w++ <br /> APPLICATION <br /> .r Non-Transferable, Revocable, and Suspends,, ; <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati isohereby ade to carryon busing in the jurisdictional area of t� a Joa in Local Heal Distric <br /> OF Business Name (DBA) 14 1 2-n Ad rens }� <br /> i Owner C 1 Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> 'n Business Telephone No. - Emergency Telephone No. p3 <br /> < y <br /> Contractor Licence No. -7 <br /> L Applicants Name (Print) (� ®y Title f11A 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) w <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. No. <br /> Tes Location - Test Date/Time g- <br /> 4.' SANITATION PERMIT + <br /> Job Address/Location - <br /> Owner - Address " <br /> 'SEPTIC TANK ❑ CESSPOOL LEACHING FIELD 7gSEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW 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 Fo"uly 1, -June 30, 19 <br /> SIZE: ❑ Less Thin 1,000 Sq. Ft., ❑ More Than 1,000 W.-Ft. <br /> ❑ DRY CLEANING,(!emicals Used/Amount/Mo. r <br /> Home awnerorliclnlfed agent'ss?ana'.vre cert;as the`.nll.*wig:"I rartify*M m the ns;rzim„ance r f Emwork farwhich this permit Isisslud,l shad not employ any perr <br /> in such manner as to become subject tow.arkmwn's com.re maticn laws Of Caliioras' <br /> Contractor's Airing or subcontracting signature c,rdtraa�the following: 1 ced fy that in the performance et:he work forwhieh fi:`. 9rnit;s Issued,I shall <br /> employ persons subject to workmali s compensation laws of California:' <br /> 1 hereby certify that I have prepared this 'pplication and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws, d rules and r u tio. f-the San Jo¢quin Local Health District. <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 &Receiyed By July 31 <br /> BILLING REMITTANCE S REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> 8 <br /> FEE <br /> LESS <br /> PRORATION PLUS <br /> ,a <br /> PENALTY <br /> OTHER ( q( <br /> OTHER <br /> Received byDate _ Receipt No. - Permit No. ssua ce Date Mai ed livered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bor 2009 STOCKTON.CA 95201 <br />