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-�- � erl Gom�.c.�... <br /> Applications WIII.Se Processed When SuppP�1CATION <br /> ,= (For Non-Transterable,Revocable,a d Suspend <br /> RIVIIT le) SEPTAGE <br /> ENVIRONMENTAL HEAL.T <br /> LIQUID WASTE ul Lo ealth Distric n,�— <br /> o, <br /> er y mad car n sines in the jurisdictional.area of the San J�q� <br /> Applicatio Address <br /> ,Business Name DBA) Address <br /> a Owner Te Telephone Num e Te <br /> sses id <br /> No. <br /> ®r Emergency <br /> U Firm Partners,_Addresses . <br /> 0. 11 <br /> Business Telephone'No. Date i <br /> Contractor Licence No. Title . <br /> r <br /> Name (Print) <br /> L Applicants <br /> lPrinte Category(1-7)and Fill'in the Required lniormation <br /> Please checkIAPp <br /> 1_ C3 PUMPER VEHICLE PERMIT REGISTRATION(FOC)isR at Sites VEHICLE) <br /> For July 1, -�-'="June 30;I9 - <br /> . <br /> CAL.License Renewal No <br /> Description(Make/Yr., C0100 CAL. License No. <br /> Serial No. - GaL,Weights &K466sdre§'NO. <br />. Capacity <br /> Equipment Parking Address <br /> 1 2, ❑ PUMPER YARD <br /> For July I'_ June 30, 19 <br /> No. of Vehicles Stored <br /> tored <br /> i No. of Chemical Toilets SR.S.or R.C.E.No. <br /> 3, ❑ PERCOLATION TEST <br /> R.S. or R.C.E.Name Test Date/Time <br /> l Test Location <br /> 4. ❑ SANITATION PERMIT <br /> Job Address Lo ation v Address ❑ PACKAGE PLANT d <br /> ' Owner � <br /> ❑ CESSPOOL VACHING FIELD _ _- EPA` E PiT ❑ OTHER�SEPTIG TANK *"a-E PERMANENT ❑ TEMPORARY ne <br /> c 5, ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Disposal Site <br /> Type Construction Equipment Storage/Cleaning Location(s) . <br /> No. of Units1, -June 30, 19 <br /> Where Certified <br /> g, ❑ PACKAGE TREATMENT PLANT For July <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7, ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: 11Less Than 1,000 Sq. Ft., [I More Than 1,000 Sq. Ft. T <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO;1 <br /> cat-on and th t the work will be done Irl accordance with San Joaquin County <br /> -1 hereby=certify„'t�hat 1 have prep re thl�pons df the Sa oaquin L I Health District. <br /> ordinarices,state laws, and r es a r.. <br /> PLICANT'S SIGNATURE X <br /> �. <br /> FOR DEPARTMENT USE ONLY t Received 13y.Juiy'31 <br /> El AMOUNT DUE CHECKED <br /> ❑ EACH ❑ January 1 &Received By January 31 ❑ ju4y REMIT_ <br /> - . Fee IS DUB: ANNUALLY ❑ PER UNIT" PER SITE REMITTANCE AMOUNT <br /> .� BILLING DATE REMITTED <br /> ty BASE ~EXPLANATION DATE <br /> FEE <br /> LESS <br /> PRORATION -Y <br /> PLUS i <br /> PENALTY <br /> OTHER <br /> OTHER <br /> V� 16 elivered <br /> Permit No ' I susnce Date Ma a <br /> Received by <br /> Date Receipt No. 1601 E.HAYELTON AVE,,P.O.Box 2005 $TOCKTON,CA 95201 <br /> ERMIT/SERYICES <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH P �,� <br />