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Applications Will Be Proud When Submitted Properly Completed.Be Sure j '"sign The Application. <br /> APPLICATION [ �� <br /> (For Non-Transferable Revocable,and Suspendable) ❑ M <br /> ENVIRONMENTAL HEALTH PERMIT 1LJ� <br /> LIQUID WASTE <br /> Application is her :y made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name(DBA) `�. /�c/GU( - Address • /5n� ���4 <br /> aOwner /1 r_1 f�C (,��c✓/? � _ Address <br /> Firm Partners, Addresses and Telephone Numbers -- <br /> eBusiness Telephone No. t.... — Emergency Telephone No. <br /> Contractor Licence NO. <br /> LApplicants Name (Print) �� [LGeI Title !2tg!:�!� Date <br /> Please check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) 5` <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 - Gat-,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 <br /> 4. ❑SANITATION PERMIT <br /> Job AddresslLocation �In ����(��7�ecr�� -rC /W72,4 <br /> O.wnnee Address _..—, , M C: <br /> tA!'SEPTIC TANK CESSPOOL ��L" AC}iING FIELD ❑ SEEPAGE PIT 13 PACKAGE PLANT <br /> [] PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19— <br /> Type <br /> 0, 19 _Type Construction _ Disposal Site _ Q <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 For July 1,-June 30, 19 <br /> SIZE: ❑'Less Than 1,000 Sq, Ft., ❑ More Than 1,000 Sq. Ft. ; <br /> Q DRY CLEANING,Chemicals Used/Amount/Mo. <br /> o ' <br /> I hereby certify that I have prepared this application and that the work will be done in accords J u County <br /> ordinances,state laws, and rules and regOation of the S n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Loo- V <br /> „ c.,-- `v <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY D'PER UNIT ❑ PER SITE ❑ EACH ❑ January t 8 Received By January 31 ❑ July t&Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE S <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> B - <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> s OT+4ER <br /> Receivetl by Dafefi.repuanee M&4 ,i : ;aelrver�¢ <br /> APPUtANT—RETURN.r4l1 COPIES TO: ENVLkoN'MENT,p1:�HEA2'1H rIMIT)SfRYlEtS _ 't601.�HAZELTGN/EVE.;eRD'Boor 20D9 ":STOCFC'!<ON,CA 96201 <br /> r ,fir�•: - - o.y- �,�, .✓?- .a- J <br />