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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION 1 <br /> I (For Non-Transferable, Revocable, and Suspendable) I <br /> y ENVIRONMENTAL HEALTH PERMIT -� - <br /> 1J LIQUID WASTE r <br /> x Applicati s hereby m Ito carryon business In the jurisdictional area of th <br /> mee San Joaquin Local Health District _ OC <br /> H Business NaIDBA n�— �T u,ce Address <br /> a OwnerE44r _ Address 17,06— /�id�Ll3FiNT` <br /> u Firm Partners,Addresses and Telephone Numbers -- -- — — <br /> ]/ / &a _ Emergency Telephone No. <br /> 'a Business Telephone No. <br /> Contractor Licence No. "` �' / <br /> Applicants Name (Print) Title &S'T Date <br /> Please check Applicable Category (1-7)and Fill In flue Required Information <br /> 1. 0 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. --- r <br /> Equipment Parking Address <br /> 2. 0 PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored " 1 <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 <br /> 4. SANITATION PERMIT �,.. fJ 02 <br /> s/LocY <br /> Job Add ation LC <e' <br /> Owner N/gpL/E SkD ,l9igk! Address <br /> ❑ SEPTIC TANK 11CESSPOOL P9 LEACHING FIELD SEEPAGE PIT 0 PACKAGE PLAT <br /> PERMANENT EITEMPORARY ❑ NEW FREPAIR 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 /> S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No.Units Served <br /> T. G 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/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, s and regulation y of t San quin Local Health District. <br /> APPLICANT'S SIGNATUREX- G L <br /> �br FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT uy PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑ July I a Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE g <br /> BASE EXPLANATIONBILLING <br /> DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE S 7 J_ J <br /> LESS y <br /> PRORATION <br /> PLUS ^- <br /> ,PENALTY <br /> OTHER <br /> OTHER <br /> Z�77 <br /> 9 9zB __ 0 7 <br /> Received by Dale Receipt No. Permit No. Issuance ate Mailed Dative d <br /> 1601 E.XAZELTON AVE.,P.O.Box E099 8T0 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ^Eta C 96201 <br />