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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District T <br /> Business Name (DBA) ddr ss. ; <br /> z Owner Address_ r <br /> a _ <br /> J Firm Partners, Addresses and Telephone Numbers , 7 <br /> a Business Telephone No. Emergency Telephone No. <br /> a <br /> -J Contractor Licence No. <br /> Applicants Name (Print) <br /> c Title —,� Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information a <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. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> 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 <br /> 3. ❑ PERCOLATION TEST <br /> I' R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Dale/Time <br /> 4. ❑ SANITATION PERMIT r r <br /> Job Address/Location <br /> t �LEACHiNG <br /> AddressOwner <br /> SEPTIC TANK ❑ C SPOOL FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 1:1 TEMPORARY 'NEW ❑.REPAIR ❑ 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 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity - <br /> t 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> k " <br /> i SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> x <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> k <br /> L I hereby certify that 1 have prepared this application a th work will be done in accordance with San Joaquin County <br /> # ordinances, state laws, an r ns e S. ocal Health District. <br /> ! APPLICANT'S SIGNATURE X ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 Receiv January 31 ❑ July 1 &Received By Joly 31 <br /> REMIT <br /> k BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE EMITT ❑ AMOUNT. <br /> I <br /> FEE LI <br /> LESS <br /> PRORATION <br /> ` PLUS <br /> f PENALTY <br /> OTHER ~ <br /> OTHER <br /> �C> <br /> µ� Issuance Date Mailed Deliver d <br /> Received by Date Receipt No Permit No. - <br /> APPLICANT—RETURN ALL COPIES TOt ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2 09 AVE., -7 <br /> T N, 95201 <br /> '�y SV�^ V01 <br />