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Applications Will Bili-Processed When Submitted Properly Completed. BeSure Ioalign IncMPIASU04-w— 1 <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) 5EP7AGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> is hereby made to c `on b s+Hess in a jurisdictional area of the San Joaqu+�,Local Health District <br /> Applicati Ql <br /> f}�G1Ce5 IJP e � f Address /�C� I�vi'I�O.v 1q <br /> Business Name {DSA} <br />` y <br /> Address <br /> q Ownerh' Cs�RG1�c <br /> Firm Partners, Addresses and Tele hone Numbers gZ 3' C C <br /> aBusiness Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) g . CA-a-C'I� Title Da <br /> te <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I For July 1, June 30, 19 i Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. Licc sse Renewal No. <br /> t Capacity Gal., Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> 3, For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> f R.S. or R.C.E. Na. <br /> R.S. or R.C.E. Name <br /> Test Location Test Date/Time <br /> I 4. ❑ SANITATION PERMIT ?f <br /> Job Address/Location <br /> f�qy8 cu. R � �,fl. R g� c�a •—C <br /> Owner Hoe Feg-r t Address <br /> ® SEPTIC TANK ❑ CESSPOOL IN LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY Qd NEW ❑ REPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1,-June 30, 19 <br /> t3U G�q 19Nk 2 7 I-e gcli L imm <br /> Type Construction Disposal Site <br /> i <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 � <br /> ` Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30,119 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 20 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application k1d that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of t San Joaquin Local Health District. <br /> j APPLICANT'S SIGNATURE X J;t Kn <br /> '. FO EPARTMENT USE ONLY, <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE. ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> a " BASE EXPLANATION BILLING REMITTANCE _ $ AMOUNT DUE CHECKED <br /> 4 DATE DATE REMITTED AMOUNT <br /> FEE L <br /> LESS 1 <br /> iPRORATION [ - - <br /> PLUS r <br /> PENALTY V <br /> F <br /> OTHER f� <br /> OTHER <br /> Received by Date Receipt No, Permit No. -.- <br /> I5 uance D to Mailed Delivered <br /> 1 <br /> APPLICANT—RETURN ALL COPIES TO:� ENYIRONMENTAL HEALTH PERMITISERYICES '`- 1681-E.HAZELTON AVE.,P.O.001 2009 STOCKTON,CA 95241. <br />