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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. .� <br /> APPLICATION <br /> c. (For Non-Transferable`Revgcabie,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH•PERMIT <br /> LIQUID WASTE nJ <br /> Application ' here mad o c ry o In s� the jurisdictional area of the San �qu ocal Health Di ct <br /> NBusiness Nam BA) ddress <br /> aOwner..,_ . Address <br /> Firm Partners, Addressesan Tgle hone Numbers <br /> a. Business Telephone No. y Emergency Telephone No. <br /> Contractor Licence No. .4 <br /> L Applicants Name(Print) -TitleQ � y Dale. Z, <br /> Please check Applicable Category (11-7)and Fill in the Required Information . , ,,_ <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; June 30, 19 - - - Disposal Sites - - -- - — <br /> Description(Make/Yr., Color) V <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment•Parking.Address �c•.r' � <br /> 2. ❑ PUMPER YARD <br /> For July 1, Junei30, 19 <br /> No. of Vehicles Stored• =� r F% { <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 /> M <br /> 4. SANITATION PERM T <br /> M <br /> Job Addr s/Location ' <br /> Owner 1 Address <br /> 11 SE TANK ElCESSPOOL 3"CEACHING FIELD 8-` PAGE PIT LJ PACKAGE PLANT " <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW FAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19Di <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) ' t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified t <br /> Plant Location ) r t <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 J <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1;000 Sq. Ft. 1 <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> lforre owner or"ceased agent'Saignature certifies thefollbwing:"1 certify in the perfirma'nce of the work for which this permit is issued,I shall not employ any person <br /> in stich manner as to become Subject to workr13n's Compeisafic;:'a',vs .alift r;;; t : i <br /> Contractor's hiring or sub-eontrarling sitzcluro car?iP're the, foijawing: 1 certify'14&'L in the performance of the work for which this permit is issubd,I shall , <br /> employ persons subject to workmaas compensation latus oMiliforria." <br /> I hereby certify that I have prepared his applic 'on hd at the work will be done in accordance with San Joaquin County <br /> ordinances, state la n rules egulat of e S Joaquin Local HealtliDistrict. <br /> APPLICANT'S SIGNATUR X <br /> ( FOR DEPARTMENT USE ONLY ) 1 <br /> j <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &,Received By July-31 <br /> -•��— - — ( REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED i <br /> 141 {� DATE DATE REMITTED t AM UNT <br /> FEE `i7 I <br /> LESS <br /> PRORATION, 14 t n �; <br /> PLUS i <br /> PENALTY ----- - --- +. . r_.. .,•=- ._: —�.� .: "� W v� <br /> OTHER t <br /> y r- <br /> OTHER <br /> Received by Date Receipt No. Permit No. 1 suance Vale Mailed I ve ed ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES '1601 E.HAZELTON AVE-,P.O.Box 2009 STOCKTON,,CA 95201 - <br />