Laserfiche WebLink
I Applications Will Be Processed When Submitted Properly Completed. BeSureTo SignTheApplication. \ <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SE;PTAGE <br /> LIQUID WASTE <br /> Applica is hereby rrl�de to car on busines i Neal is c <br /> ,�Business Name (DBA} A& �; ��`- . Addressr� 4 - <br /> i Owner Address <br /> Firm Partners, Addresses and Tele Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> i <br /> LApplicants Name Title ater4 <br /> Please check Applicable Category (1-7)and Fill in the Required Information . <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) C1J For July 1, June 30, 19 Disposal Sites - _ - <br /> Description(Make/Yr., Color) 1i <br /> Serial No. CAL. License No. CAL. Lic:nse_Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 3 2. ❑ PUMPER YARD Mf <br /> is For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t '' <br /> 3. ❑ PERCOLATION TEST 5", <br /> R.S. or R.G.E. Name ' R.S. or R.C.E. No. <br /> } Test Location Test Date/Time <br /> 4 R q, Z- TATION PERM f {. r. ,1,• <br /> Job S IAddre <br /> Owner Address <br /> ��PTIC TANK CESSPOOL 9'C�CHING FIELD PAGE PIT ❑ PACKAGE PLANT `fes <br /> # Q';If-Rff'MANENT ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER i(w <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 , <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s)A� -s <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 .r, C�' <br /> Operator Name -� Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served ?' <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> e SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft, <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Thu <br /> I hereby certify that 1 have pare is application and th rk will be done in accordance with San Joaquin County <br /> ordinances, state laws, en ules ions of a ocal Health.District. + '� <br /> APPL '~ a <br /> en— <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY- " -.PER UNIT. ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By•Jbly 31 <br /> ^� gCHE�KE <br /> ' r LLING —F[Etv11c1TANE:E $ r AMOUNT DUEBASE EXPLANATION . i7ATE }' e i`� s� f7AT,E REMITTED <br /> ,r� �'-� <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Z <br /> PENALTY <br /> OTHER <br /> OTHER �a a <br /> Received by Date Receipt No. Permit No. I suanc D Mailed Delivered <br /> k APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON .O.Box 2009 - STOCKTON,CA 95201 <br />