|
ti.
<br /> ems' 5ure iv
<br /> Applications Will Be Processed When Submitted Properly Completed. e
<br /> �- APPLICATION
<br />.0 (For Non-Transferable, Revocable, and Suspendable) SEPTAGE ti
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE ist,ict
<br /> CIt✓
<br /> Applica6;wywyl����
<br /> aA�dressth an Joaquin `al
<br /> ' ll7-01
<br /> mBusiness Name (DBA) Address
<br /> i Owner
<br /> a ne N rs
<br /> J Firm Partners, Addresses and T S Emergency Telephone No"
<br /> aBusiness Telephone No. g Q
<br /> j Contractor Licence No. Title Date
<br /> Name (Print "{
<br />` Applicable Category (1-7)and Fill in the Required Information
<br /> Please check App' -
<br /> 1 ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> June 30, 19 Disposal Sites y
<br /> For July 1,
<br /> Description_(.Make/_Y.r.,-COIOr) r License No. CAL.License Renewal No. �I
<br /> .CAL.
<br /> Serial No.
<br /> Capacity Gal.,Weights & Measures_No".-
<br /> Equipment Parking Address t
<br /> 2, ❑ PUMPER YARD
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored
<br /> No. of Chemical Toilets Stored -
<br /> M 3, ❑ PERCOLATION TEST R.S.or.R.0-.E_No.,_
<br /> 1. R.S. or R.C.E. Name Test Date/Time
<br /> f Test Location i 1. f -"
<br /> f 4, ❑ SANITATION PEF!,Rff, 17,1
<br /> 1
<br /> Job Addres cation ;
<br /> Owner i'4 •Address PIT ❑ PACKAGE PLANT
<br /> I�"CEACHING'F,IELD 5 QKOTH4R 04�
<br /> ❑ SEPTIC TANK ❑ CESSPOOL rte• �EP
<br /> *-lr'ERMANENT ❑ TEMPORARY'-- ❑ NEW 3 1
<br /> i - #
<br /> 5• ❑ CHEMICAL TOILETS' For JLIy 1, -June 30, 19 t
<br /> 1 Disposal Site a
<br /> Type Construction 4
<br /> No. of Units Equipment Storage/Gleaning Locations) J
<br /> I t
<br /> I 6, ❑ PACKAGE TREATMENT PLANT For July 1, -JuneY30, 19 # Where Certified' "
<br /> Operator Name
<br /> Plant Location ) No. Units Served"',-
<br /> Plant
<br /> erved"', -Plant Capacity ` '
<br /> 4
<br /> 7. ❑ LAUNDRY For July 1, -JUne•3Q 19
<br /> ❑ 1000 Sq- Ft., ❑ More Than 1000 Sq Ft.
<br /> SIZE: Less Than , °'4. " �� 4 � �, =r"'�-,•
<br /> r ❑ DRY CLEANING,ChemicalsUsed/Artount/Mo.
<br /> t ' r
<br /> STA
<br /> I.
<br /> U-
<br /> is-,a lication andtt ye"work•,nr_ill be done
<br /> 'in accordance with San oaquin Count
<br /> I hereby certify that I have prep dp a ui ca th District. i
<br /> I. ordinances,"state laws,
<br /> a regul "ons of the'
<br /> APPLICANT'S SIGNATU
<br /> i A r { s
<br /> r
<br /> r "._ FOR,DiPARTMENT USE ONkY-----•-••% I
<br /> ,i
<br /> • _ c .l ,.,,, Jul 1 &Received;,By July 31
<br /> J ❑pFS SITE 't0 EACH ❑ January 1 &Received By January 31 ❑ y REMIT
<br /> ✓' r _
<br /> Fee Is Due. ❑ ANNUALLY ❑ PER UNIT r. REMITTANCE $ AMOUNT DUE CHI=,CKED
<br /> �'" / BIIdLING AMOUNT '
<br /> REMITTED
<br /> EXPLANATION, DATES, DATE e -
<br /> FEE
<br /> LESS ✓ r „_
<br /> PRORATION
<br /> I PENALTY
<br /> r ,
<br /> OTHER
<br /> OTHER
<br /> �' T ��� Issuan Date Mailed Delivered
<br /> Receipt No. Permit No.
<br /> Received by
<br /> Date 1601 E.N,gYELTON AVE.,P.O:Box 6009 sTOCKTON,CA 95201 -�
<br /> TO: ENVIRONMENTAL HEALTH
<br /> y
<br /> APPLICANT—RETURN ALL COPIES PERMITISERYICES
<br /> ,
<br />
|