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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The Application. 4 <br /> !, APPLICATION . . <br /> (For Non•Trarisferabte,Revocable,and Suspendable) $EPTn;,r. : <br /> +' ENVIRONMENTAL HEALTH PERMIT <br /> Irl LIQUID WASTE <br /> n Appiication is hereby mago carry_gn bu,in ss in,the' rls Ictional area of the Safi 4&a uin a[ Ith Di tact <br /> t� O <br /> r Business ame(DBA) <br /> Lx I <br /> Owner ^ [ - --Addres ^ <br /> i Address�a <br /> �=. < <br /> "Firm Partners,Addresses and Telephone Numbers --- <br /> Business Telephone No. s SQ r� Emergency Telephone No._.,-.�1j�� --- � � <br /> t� Contractor Licence No. _ `. - . <br /> ;R _—Title _ _Date <br /> ec L Applicants Name(Print)_ (Zlu 77--G�� <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PLIMPER VEHICLE PERMIT REGISTRATION jFOR EACH VEHICLE) _ 3� <br /> For July 1, June 30, 19 Disposal Sites _.— <br /> rr <br /> Description(Make/Yr.,Color] — _ ---------- — - ti <br /> Serial No.- _—,� CAL.License No. —_CAL.License Renewal No. h' <br /> ii <br /> Capacity r Gel.,Weights&Measures No._r --- ---- ' <br /> f Equipment Parking Address <br /> 2. ❑ PUMPER YARD k <br /> For July 1, June 30, 19 -- ` <br /> i No.of Vehicles Stored <br /> No.o1 Chemical Toilets Stored_----- --- -- --------- - <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.G.E,Name ___ _,__ _- R.S.or R.C.E.No. - <br /> f 5 Test Location -- --- Test Dale/Time <br /> i <br /> 4. ❑ SANITATION PERMIT <br /> #, Job Addie <br /> O er. S5 Address <br /> EPTIC TANK CESSPOOL LEACHING FIELD] ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> £ PERMANENT ❑ TEMPORARY KNEW ❑ REPAIR ❑ OTHER # <br /> r w <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction_-- Disposal Site <br /> i No.of Units ---. Equipment Storage/Cleaning Locatinn(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> +, Operator Name --- ----- --- -- --- -- — <br /> Plant Location — - ------ - ---- - --- ---- --�._ .�._._.. ---- -_-- H <br /> Plant Capacity No. Units Served <br /> 1 7. ❑ LAUNDRY For July 1,-JUnO 30. 19 <br /> d <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq.Ft. <br /> i� <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. - -- -- -- �. <br /> _ •��-q „i <br /> I hereby certify that I have prepared this application and that the work wit a don in accordance with San Joaqu' ounty <br /> ordinances,stale laws,an rule and regulations f the San Joaquin L cal Health Dis;ctL <br /> i <br /> APPLICANT'S SIGNATURE X — = <br /> C _ <br /> FOR DEPARTMENT USE ONLY + <br /> Fee Is Due:U ANNUALLY Q PER UNIT Q PER S1TF Q EACH ❑ January 1 a Recarved By January 31 ❑ July 1 A Rece;ved Ery Joly 31 <br /> BILLING j REMITTANCE AMOUNT DU HECKE6 'I <br /> BASE EXPLANATION DATE DATE I REMITTED 1 <br /> VEE <br /> LESS <br /> PRORATION <br /> - PLUS I <br /> DTOT <br /> "ER <br /> priIEH <br /> Issuance D ailed Dollvnled��_____._..�. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTO P.O.Boa 2000 tiTOCKTOH,CA 95201 <br />