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Applications Will Be Pr sed When Submitted Properly Completed. Be' To Sign The Application. <br /> APPLICATION / .'34 <br /> (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application js hereby made to carry on pusiness in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Ste, -fried dF-n lL1Q^�1� q q Adpd�ress 4�',0, 4�S !� V e , <br /> OwnerJ�___Q __�11" 1d ---�U ba4 Address - _1 - ,v ' <br /> Firm Partners, Addresses and Telephone Numbers <br /> � Business Telephone No. 9Q __ -___-_-_ Emergency Telephone No. <br /> c <br /> Contractor Licence No. _ <br /> = Applicants Name (Print) Stan OS J q _-_____ _.._._____-.-__ Title � �I1-1--_._----_-- Date -P- 12 - QZ_ <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. License Renewal No..-- <br /> Capacity Gal., 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. 0 P LATION TEST <br /> R.S. or ,Name Roker t��_ Ce hi pn __ R.S. or C No. _ S `� /_� `___ _7 9 <br /> Test Location _54 q N . Nehvf l-t R 4. Test Date/Time _�--J!/ `.— �.( c <br /> 4. ❑ SANITATION PERMIT 21 2_ <br /> Job Address/Location _ -__ V_1_ ' __-`3 <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 iri accordance with San Joaquin County <br /> ordinances, state laws. <br /> /I - /2-az <br /> APPLICANT'S SIGNATURE X _. _-_- -_- Title Date - -1 _ _ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> �y AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER � - --- - -- ----- - - --- —� -- ----- <br /> Received b ate `71 Receipt No Permit No Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPI T : ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />