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Applications Will Be Proce-ed When Submitted Properly Completed. Be SI 'o Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i ereby made to carr on business in the jurisdictional area of the San Joaqu Local Heai/t1h DiisstrictQ ` <br /> Business Name (DBA) 0 4VA L-D �� i?y• Address <br /> 7 , ��0�1� H�C cL�� �,d.L • <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers - <br /> Business Telephone No. U t�S� Emergency Telephone No. <br /> Contractor Licence No. p <br /> Applicants Name (Print) D L,r L LWM-- Title 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. ❑ ATION TjST r <br /> R.S. o R.C.E. ame _ (�-oi'JA`� a Lr R.S. R.C.E. No. IG 8 <br /> 0 - 00 <br /> Test Location ��• -t-L-{-ti-�L1E�� 1�- �'S Date/Time ESIsD W�S� or- EXISTIA ` <br /> 7. ❑ SANITATION PERMIT N�S j Z U 3`f - <br /> job Address/Location - - <br /> Dwner - Address <br /> D SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> :] PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> i. ❑ CHEMICAL TOILETS For July 1, - June 30, 19 <br /> Type Construction Disposal Site _ <br /> :o. of Units - _ --- Equipment Storage/Cleaning Location(s) <br /> ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19 - <br /> Where Certified -- --- - <br /> )perator Name <br /> dant Location ---- _ <br /> No. Units Served <br /> 'Iant Capacity — -- <br /> ❑ LAUNDRY For July 1, - June 30, 19 <br /> -1ZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> J DRY CLEANING, Chemicals Used/Amount/Mo. -- <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. (A q <br /> Title Date <br /> ,APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DUE: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1REMIT <br /> IL Received By January 31 ❑ July 1 b Race�ved By July <br /> El <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> I r <br /> FEE ,oil <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Permit No. Issuance Date Mailed Detivered <br /> Received by Date Rece-pt No STOCKTON.CA 9520 /II <br /> -K0+r �2ELTON AVE.,P.O.601 2009 rt r.l <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES E X H 17P) IT 44 <br /> /;'— <br />