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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> i (For Non-Transferable; Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE —� <br /> ` Application ' hereby ma4e to carry o business i thej' sdictional area of the S n Joa uin Local alth District <br /> yBusiness Name DBA) G Address <br /> z Owner Address �— <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 3 46 Y -6I(6'rEmergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print). /�i� S T 4 Title Date <br /> Please checkApplicableCategory (1-7)and Fill in the Required Information <br /> 1, 13PUMPER-VEHICLE.PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,,19 Disposal Sites <br /> Description(Make/Yr., Coloi•) <br /> i <br /> Serial No. CAL. License No. CAL. License Renewal No, <br /> Capacity Gal.,Weights & Measures No. � A <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD 14 <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored = <br /> t No. of Chemical Toilets Stored` <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name n , R.S. or R.C.E. No. <br /> Test Location ` ' )v Test Date/Time <br /> firf <br /> i 4. ❑ �'�SANITATION PERMIT <br /> + Job Ad�re�socation �"rOw er _ - Address f+ <br /> I L7f5EPTIC TAN ESSPOOLACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> C PERMANENT ❑ TEMPORARY n NEW 11REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-lune 30, 19 <br /> Type Construction ! Disposal Site T <br /> F No. of Units " Eq iipm_en Storage/Cleaning Location(s) J <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant LocationI <br /> Plant Capacity }F f No. Units Served <br /> 7. ❑ LAUNDRY For Julya---June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Afnount/Mo. <br /> I hereby certify that I have prepared this and that the work will be done in accordance'with San Joaquin County , <br /> ordinances, state laws,-and rule nd regulataw;;� <br /> Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY © PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JOy 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> S y�[ s <br /> i FEE <br /> LESS <br /> PRORATION -- <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> � t 37 <br /> /S _7 <br /> Received by Date Receipt No. L Permit No. issuance ate. Mailed eliver d <br /> APPLICANT—RETURN ALL C - IESS TENVIRONMENTAL EAT ER SERVIC 7601 E.liA2ELTON AVE.,P.O.Box 2009 .STOC TON,C 95201 <br /> r 7 <br />