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Applications Will Be Prc�ed When Submitted Properly Completed.Be SurSign The Application. f{ <br /> APPLICATION <br /> ' �� (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT J 4 <br /> LIQUID WASTE �� v Q <br /> Applicatlon is h by made to ca on siness in the jurdictionai area of the San Joaquin Local Health District 4 . Address <br /> " ' <br /> Business Name BA) - I <br /> aOwner Address f <br /> Firm Partners,Addresses and Telephone Numbers <br /> IL business Telephone No. ,�:5/F S- — Emergency Telephone No_ <br /> 1 <br /> a <br /> Contractor Llcence No. 4pate �2 <br /> Applicants Name (Print) Title <br /> ` Please check Applicable Category(1-7)and Fill in the Requ red information I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> I Description(Makelyr„Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> t <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 /> Test Location Test Date/Time i <br /> 4. ❑ SANITATION PERMIT �m�O Addres! m�O <br /> Job /Lo tion �f <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD EPAGE PIT ❑ PACKAGE PLANT ; <br /> ❑ PERMANENT 11TEMPORARY ❑ NEW REPAIR 11 OTHER 0 1 <br /> i 5. ❑ CHEMICAL TOILETS For July 1,-June 30. 19 +401-4 a <br /> Type Construction .Disposal Site a 1 <br /> No.of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules an ulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIG NATURE - <br /> FOR DEPARTMENT USE ONLY y'(``'�,�� <br /> Fee Is Due: O ANNUALLY ❑ PER UNIT El PER SITE 13 EACH ❑ January 1 &Ae ived By Janvary 37 ❑ July 1&Received 13y July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMIT ANCE S AMOUNT DUE CHECKED <br /> DATE D REMITTED AMOUNT < <br /> FEE <br /> LESS <br /> I PRORATION <br /> 3 <br /> PLUS <br /> PENALTY <br /> - OTHER <br /> �. OTHER <br /> t 3\a9r <br /> Iu` ej t <br /> :i- Received by Date Receipt No. rmit No.- Issuance Date Malted Delivereq I <br /> APPLICAN = <br /> TRETURN ALL COPIES TO:. ENVIRONMENTAL HEALTH PERMITISERVICES 7604-E.HAZEtTON AVE-,P.O.Bow 7009 . S;UC%TON.'G,9 1 r� n <br /> v <br />