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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. T - <br /> APPLICATION <br /> (For Non-Transferable, Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby mad o carry on business in the jurisdictional area of the San Joaquin Local Health Diarict� <br /> +n Business Name (DPA) n ; Address 2 <br /> a Owner P A -r!� �✓ � l Address <br /> i <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL Business Telephone No. �{� f�"� G Emergency Telephone No. <br /> Contractor Licence No.T ; <br /> Applicants Name (Print) �/Y) t 4_ Title ` Date <br /> Please check Applicable Category (1-7) and Fill in the Required Information / d <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 /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time ' <br /> 4. IV SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> WTIC TANK CESSPOOL LEACHING FIELD � SEEPAGE PIT ❑ PACKAGE PLANT <br /> ANENT ❑ 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 /> 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. � t <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MMo. <br /> I hereby certify that I have prepared this application and that the-work will be done in accordance with San Joaquin County <br /> I <br /> rdinances, state laws, and r I and regulatiMsof heS Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X--�` ; <br /> .ems <br /> : FOR DEPARTMENT USE ONLY <br /> Fee IS Due: El ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑.July 1 &Received By July 31 <br /> REMITa <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED q� AMOUNT <br /> FEE <br /> LESS <br /> PRORATION J <br /> PLUS <br /> C PENALTY . +' v <br /> OTHER <br /> OTHFW <br /> Received by Date Receipt No Permit No. Issuance ate - Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: .r ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AV`PvO 13 2009 S OCKTON,CA 95201 r; <br />