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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION ;. <br /> (For Non-Transferable, Revocable, and Suspendable) S <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE i <br /> LIQUID WASTE <br /> Application is her by m d to car b sitiess in the' ' c1ictional area oft a ul Lo Health Dist ict <br /> y Business Name (DBA) � P�ddress <br /> �'t L �€ <br /> z Owner L.t� +` �-- .I�. Address <br /> Firm Partners, Addresses an T e hone Num• er <br /> Ir �- <br /> K Business Telephone No. Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> a_ . 1 Y j C- �' L © Date . <br /> A Ilcants Name {Print - `"{ �� � Title <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. Liccnse Renewal No. <br /> Capacity . 4Gal:, Weights, Measures-No.- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of vehicles Stored �� _ �- <br /> ----- <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST .* <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location I� Test Date/Time <br /> 4. ❑ SANITATION PE IT <br /> Job Add Location <br /> caner �S �'' Address <br /> SEPTIC TANK CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT, ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> I H -¢ <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 { <br /> Type Construction �N Disposal Site <br /> No. of Units IM Equipment-Storage/Cleaning Location(s) <br /> 6. .❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - - Where Certified <br /> --Plant Location i! # <br /> Plant Capacity No. Units Served _ <br /> 7. T❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 5q. F0, 11 More Than 1,000 Sq. Ft. , <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> -r <br /> r.. <br /> i' <br /> I hereby certify t, have prepared this application and that the work will be done in accordance with n Jo u o my <br /> ordinances, state laws, d rules and gula n oaquin Local Health District. - <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> r Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &R c ive uary 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE .� EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT- <br /> II <br /> IJ <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS M <br /> PENALTY It a <br /> OTHER <br /> OTHER - <br /> Received by Date IS. . Receipt.No. "-F 'Permit No. ' Is Date ~� Mailed Delivered f Y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />