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Applications Wili Be Processed When Submitted Properly Compleled. Be Sure To Sign The Appllcation:;�-- <br /> � y hi APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> I �I LIQUID WASTE <br /> Application i hereby ma a to carry on usiness in the jur' ictional area of the SJ 'oaquin Local Health Dist t <br /> F Business Name (D } Address <br /> aOwner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> CL <br /> Business Telephone No. ! Emergency Telephone No. <br /> Contractor Licence No. 2 <br /> a Applicants Name (Print) Title /C <br /> 0411-� %'-• F 1 Date <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, t June 30, 19 Disposal Sites <br /> Description.(Make/Yr., Color)a-4, 1 <br /> Serial No.� CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No, <br /> Equipment Parking Address ii <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored I <br /> No. of.Chemical•Toilets Stored <br /> 3. ❑ PERCOLATION TEST" 11 <br /> R.S. or R.C.E. Name -R:5-or R:G.E. No. <br /> Tesf L atio� �' !T s,. #may <br /> « +� Test Date/Time <br /> ok <br /> 4. LU SANITATION PERMIT <br /> Job Address/Locationro.2 <br /> ,O.,wn li ` Address A <br /> G <br /> ,?�'S�IC TANK r 11CESSPOOi_ E L ACHING FIELD SEEPAE PIT �❑ PACKAGE PLANT � <br /> i 1-e'PERMANENT ❑ TEMPORARY II NEWf� (] REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 F # S <br /> Type Construction 0 Disposal Site <br /> No. of Units l Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT,PLANT For July 1, -June 30, 19 004 , <br /> . Operator Name Where Certified <br /> Plant Location II <br /> Plant Capacity II No. Units Served 4 <br /> 7. ❑ LAUNDRY For July 1, -'`June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accorda`ne•with San Joaquin County <br /> ordinances, state laws, and rule and regulations o he FAan Joaquin Local Health District. �f e <br /> # APPLICANT'S SIGNATURE X �t -g <br /> I� TTE <br /> PARTMENT USE ON!Y <br /> 1!!!! <br /> REMIT <br /> Fee IS Due: ❑ ANNUALLY li ❑ PER UNIT ❑ PEI EACH ❑ Ja ary Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION REMITT C $ AMOUNT DUE CHECKED <br /> DA REMITTED 4 AMOUNT <br /> FEE ,LESS <br /> PRORATION It { - <br /> PLUS A ; <br /> PENALTY <br /> OTHER <br /> OTHER - <br /> I) 7. z G <br /> Received by Date Receipt No. Permit No Issua ate Mailed Delivered <br /> I APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2049-- STOCKTON,CA 95201- <br /> . a - <br />