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Applications Will Be Pro? Ned When Submitted Properly Completed. Be Sill", o Sign The Application i <br /> APPLICATION I ; <br /> (For Non-Transferable,Revocable, and Suspendable) Q <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 1.191110 WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,F Business Name (DBA} Address <br /> i Owner D] L. . c-�- BARUZO-W Address 2 - f <br /> Firm Partners, Addresses and Telephone Numbers - — (31 <br /> a. Business Telephone No. (7-09) 935--4?9R.(KE1ctkJl COWNSO Emergency Telephone No. �9 <br /> a <br /> Contractor Licence No. <br /> Applicants Name (Print) E I CIO RTt-5. -_ Title Date < . <br /> Please check Applicable Category (1-7)and Fill in the Required Information G:,1✓> # i1SEA- <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4-(8 m"ew PLA2A <br /> For July 1, June 30, 19 Disposal Sites 1 Gaft�GFe- cjrj� <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. A <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. X PERCOLATION TEST (.8'"Jil 5 <br /> - R.C.E. Name 4VAl-T`tR �. cli 1pa'I 'f R.C.E. No. <br /> Test Location - r = CY Test DateMme <br /> 4. ❑ SANITATION PERMIT 2VIA Rr.F-L5, 2,1:,-2L.ACP_E:, tEAc 4 R'AblWG5 <br /> Job Address/Location t,SEI~ Bf1G sibE 'F<YQ �_Oc_A-LrtotA _ <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ 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 /> 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 /> ❑ 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. <br /> APPLICANT'S SIGNATURE X- Title - Date �� '.9 - <br /> FOR DEPARTMENT USE ONLY <br /> Fee 118 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE QU U Q <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER Ad <br /> ytv- <br /> Received by Date Receipt No. Permit No. Issuance Date Melt d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2668 STOCKTON.CA 95201 <br />