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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />s APPLICATION <br />For Non-Transferable, Revocable, and Suspendable) <br />SE PTAGE <br />s <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />ApplicationxPreby made o cart Son siness in the jurisdictional area of the San JoaquinAo I Health District S <br />rn <br />Business Name (DBA), Address <br />z Owner GAS P,¢, is Address lF <br />a <br />kJ,Firm Partners, Addresses and Telep one Numbers <br />aBusiness Telephone No. Emergency Telephone No. <br />Contractor Licence No. oe <br />LApplicants Name (Print) Title Date <br />Please check Applicable Category (1-7) and Fill in the Required Information. <br />1. 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. Liccr:se Renewal No. <br />Capacity_ Gai.,--Weights &Measures No. <br />Equipment Parking Address <br />2. PUMPER YARD <br />For July 1, June 30, 19 <br />k 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 G <br />Job Address/Location <br />Owner ter I Address <br />SEPTIC TANK CESSPOOL I K LEACHING FIELD SEEPAGE PIT PACKAGE PLANT 1 <br />11 PERMANENT, [] TEMPORARY 11NEW REPAIR 1 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. a y+ 'd% <br />DRY CLEANING, Chemicals Used/Amount/Mo. <br />I hereby certify that I have ared this appl' do nd that t wo ill be done ordanw- with San Jdtiquin County <br />ordinances, state laws, a ' s nd regulati n e San Jo in Local Hea District. <br />APPLICANT'S SIGNATURE X f <br />I <br />FOR DEPARTMEN USE ONLY <br />Fee IS Due: 11 ANNUALLY PER UNIT PER SITE 1:1 EACH, January 1 &Received By January 31 July 1 &Received By July 31 <br />BILLING REMITTANCE <br />REMIT <br />BASE EXPLANATION <br />DATE DATE REMITTED <br />AMOUNT DUE CHECKED <br />AMOUNT <br />I FEE p-4-7 75 15-- <br />LESS <br />5- <br />LESS <br />r PRORATION <br />Ptus <br />PENALTY <br />IOTHER <br />OTHER <br />G 41 y a <br />Received by Date Receipt No. Permit No._Assu rice Dae Mailed Delivered <br />APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,-CA 95201 f