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w Applicati'URiilhsg P4QQ!@ed When Submitted Properly-Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> SAN ,1i.AQU;iN -Transferable, Revocable, and Suspendable) SEPTAGE <br /> HEALTH aIIST,RIU"VIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> y Business Na//mooe�� (DBA) Q Address P.0__-1307< � C 9536 <br /> j 6-14 qmo At <br /> a Owner ckp Buck- Address <br /> 0 Firm Partners,Addresses and Telephone Numbers 04 L9 Q?5361 <br /> CL Business Telephone No._ ���$� Emergency Telephone No. '� <br /> � <br /> Contractor Licence No.. Cf <br /> Applicants Name (Print) u Title Own�� Date �"' 'S '� <br /> Please check Applicable Category (1-7) and Fill In the Required Information (~ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> b For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) - <br /> Serial No. CAL. License No._331 130' -CAL. License Renewal No. ' <br /> Capacity Gal., Weights & Measures No. <br /> r Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored s <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. A SANITATION PERMIT��y, �t /�,� <br /> Job Address/Location 1_f024 C4aNY R . - <br /> O,.,,,,w,//ne�er Address <br /> I ker IC TANK �OCE�SSPOOL� LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ` 11PERMANENT 1:1TEMPORARY C1NEW 11REPAIR ❑ OTHER <br /> ' 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 C <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> r ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> t ordinances, state law les and regulations the San Joaquin Local Health District. <br /> k APPLICANT'S SIGNATURE X n L 00 <br /> o <br /> FOR DEPARTMENT USE ONLY <br /> i Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Juty 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> /')I C�; 9 3 sls 6 6713-3 g a 8D <br /> Received by ate I Receipt No. Permit No Issuance Dat Mailed Delivered - <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t1601 E.HAZELTON A .8ox 20 STOC%TON;CA 95201 <br /> k �G+ <br />