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Fill <br /> Applications Will Be Processed When Sup e eBe <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 4 ' ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application is he.reby made to carry on business in the jurisdictional area of the San Joaquin Local HHeaIth District <br /> �73; Address <br /> y Business Name (DBA) D. <br /> Address <br /> a Owner <br /> J Firm Partners, Addresses and Telephone Numbers Emergency Yelephone No. <br /> CL Business Telephone No. ��� � <br /> a 3 _ <br /> _jContractor Licence No. —� ,� �,��� Titie � pate <br /> Applicants Name (Print) "` <br /> Please check Applicable Category (1-7)and Fill in the Required information t . <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) A CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity I ' Gal.,Weights & Measures No. <br /> Equipment Parking Address• <br /> 2. ❑ PUMPER YARD <br /> For July 1, e June 30, 19 <br /> No. of Vehicles Stored i <br /> l ; <br /> No. of Chemical Toilets Stored - <br /> 3,. ❑ PERCOLATION TEST_ R.S. or R.C.E. No. <br /> l R.S.or R.C.E. Name' <br /> Test Date/Time <br /> Test, Location <br /> M <br /> q, SANITATION PERMIT f <br /> Job Address/Location <br /> � <br /> Owner , Address <br /> On . ^ <br /> I er TANK {� ❑ CESSPOOL M-TEACHING FIELD P'IEEPAGE PIT _,.PACKAGE PLANT <br /> ❑ REPAIR ❑-OTHER <br /> ' C�PERMANENT 13TEMPORARY t ffKEW - <br /> 5. ❑ CHEMICAL TOILETS For July`.1'-June 30, 19 s <br /> I Type Construction Disposal Site 4. <br /> No. of Units <br /> I. i ` ; Equipment Storage/Cleaning LoGation(s) t ) <br /> a_ q w Q <br /> 8, ❑ PACKAGE TREATMENT PLANTU or July 1, -June 30, 19 r # <br /> +� _ Where Certified � <br /> Operator Name r'r w Y +� s i <br /> k Plant Location ; - �. <br /> No. Units Served^ <br /> Plant Capacity <br /> 7. 11 LAUNDRY For July 1, -June 34, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. I _ _ <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> � ar- <br /> ' `� � t <br /> I hereby certify#that''I have prepared this application and that the work will,be'done in accordance with San Joaquin County 1 t <br /> $ ordinances, state laws, vies and regul ions of the S n Joaquin oc�Health District. J <br /> 4 i <br /> APPLICANT'S SIGNATURE { <br /> r S. E <br /> v v <br /> i <br /> t , I FOR DEPARTMENT USE ONLY <br /> I 11 s-j...."' I -n 9 By <br /> Fee IS Due' ❑ ANNUALLY. ❑ PER UNIT ❑ PER SITE ❑,.EACH'_ ❑ January 1 &Received By January 31 ❑ July 6 &Receij REMIT 31 1 <br /> CHECKED <br /> BILLING" REMITTANCE $ I.- AMOUNT DUE AMOUNT a <br /> 4 <br /> BASE EXPLANATION DATE DATE REMITTED �_7 ` <br /> FEE <br /> LESS 1 4 { d # <br /> PRORATION <br /> a <br /> PLUS <br /> PENALTY .�. <br /> OTHER " <br /> �� f <br /> OTHER <br /> Date Receipt No. Permit No- <br /> lssu nce D to C r,. Mailed Delivered <br /> r <br /> Received by '1601 E'.`HAZELTON AVE:;'P.O:Box 2009"°'STOCKTON,CA 95201 rte` <br /> APPLICANT=RETURN ALL'COPIES TO "'�ENVIRONMENTAL HEALTHPERM1T15ERVICES'""` `�E- <br />