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Applications Will Be Processed When SuAPPLICperly cl <br /> } (For Non-Transferable,Revocable, and Suspendable) $EPTAGE <br /> C � <br /> �•� - � ENVIRONMENTAL HEALTH pERMIT <br /> �a.. L{Q01p WASTE <br /> made to car on business in the jurisdictional area of the San Joaquin Local H I DistrictYVI <br /> - <br /> le �Lli <br /> s <br /> is hereby �- Address <br /> , or <br /> F Business Name (DBA) Address <br /> >U <br /> a Owner <br /> J Firm Partners, Addresses and Tele one Numbers <br /> Telephone No. <br /> 1 11110,11Emergency <br /> aBusiness Telephone No. ( 1111'sille III Date <br /> }Contractor Licence No. _57 Title . <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required I , <br /> nformation <br /> I, 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) -t <br /> r( Disposal Sites <br /> For July 1, June 30, 19 ------------ , <br /> CAL. License Renewal Na. <br /> Description(Make/Yr.,Color) CAL. License No. x <br /> Serial No. GaI.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 — <br /> No. of Vehicles':Stored Y <br /> k <br /> No. of Chemical Toilets Stored - <br /> 3, ❑ PERCdATION TEST R.S:or R.C.E.No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location _ <br /> j 4 C3 SANITATION PER <br /> 014 <br /> MiT r_ <br /> F Job Address/L-ocatiori E� Address r r� <br /> F ❑ PACKAGE PLANT <br /> own ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ OTHERS' <br /> (d'SEPTIC TANK ❑ + ❑ NEW ❑ REPAIR - q [� <br /> ❑ PERMANENT TEMPORARY <br /> [ <br /> 5. C3CHEMICAL TOILETS For July 1,-June 30, 1Dlspo 5le --. <br /> - 1 i F <br /> Type Construction 1 -.* <br /> D.-m <br /> Equipment,•Storage/..Cleaning Loc'ativn(s) I <br /> No. of Units <br /> _..- :Where Certified <br /> 6. ❑'PACKAGE TREATMENT PLANT For July 1, -June 30, 19r ; <br /> £- <br /> Operator Name <br /> Plant Location } �A No.'Units Served ` <br /> plant Capacity._ _ _> <br /> 7, ❑ LAUNDRY- For July, June 3b, <br /> ❑ Less Than 1,040 Sq. Ft., ❑ More Than 1,000 SgFt. 1 <br /> SIZE: + <br /> M ❑ DRY CLEANING,Chemicals Used/Amount/Nio. � <br /> prepared this app <br /> Ilcation and that'the work wi11 be done in accordance with San Joaquin unt 4 <br /> 1 hereby certify that i have pre P <br /> t n regulations of;the San Jo{quin Local <br /> ordinances, state laws, and rulbs`.aHealth District. <br /> z _ I <br /> n \ 1 <br /> APPLICANT'S <br /> ; b <br /> OR DEPARTMENT USE ONLY <br /> 31 ❑.July 1 &Received By July 31 <br /> -❑ January 1 &Received By January REMIT <br /> PER SITE �'❑ EAGi-1 CHECKED <br /> } Fee Is Due: C1 ANNUALLY <br /> PER UNIT REMITTANCE $ AMOUNT DUE AMOUNT <br /> BILLINGi DATE REMITTED , <br /> BASE EXPLANATION. DATE <br /> ± L <br /> FEE 3 i <br /> i` LESS <br /> { PRORATION <br /> 4 PENALTY <br /> OTHER• ; <br /> OTHER +J <br /> Delivere <br /> { , issuance Date Mailed <br /> - - .Permit No. TON, <br /> Received <br /> CA 5201 <br /> pate f j _ Receipt No. AVE.,P.O.Box 2009 1 <br /> Received by <br /> ENV YICES 1601 E.HAYEL70N ON HEALTH PERMITISER1 <br /> .,APPLICANT—RETURN ALL COPIES TO, <br />