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Applications Will Be Processed When Submitted Properly Completed. Be Sure <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL.-HEALTH PERMIT <br /> LIQUID"WASTE <br /> Applicati 's hereby mad to.car ostrict f— <br /> n bu s in the jurisdictional area of t1e-SaILJoaq�uin Loll He Di <br /> r• Address f Ih ' <br /> NBusiness Name (DBA) Address <br /> i Owner II <br /> K <br /> J Firm Partners, Addresses and Te e e Num Emergency Telephone No. <br /> a Business Telephone No. �i <br /> Q r r <br /> Contractor Licence No. _Title Date <br /> L Applicants Name (P ' <br /> 1 7 and FIII in the Required Information <br /> Please check Applicable at <br /> ( - ) ILiI <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites .y f <br /> Description(Make/Yr., Color) CAL. License.Renewal Ng <br /> Serial No. CAL. License No. ;`- <br /> Capacity <br /> Gal., Weights & Measures No. <br /> Equipment Parking Address ' <br /> 2. ❑ PUMPER YARD p� <br /> For July 1, Jur1e 30 19-^. <br /> No. of Vehicles Stored ��� � ---� - -- <br /> No;of`Chemlcal Toilets 5tored,� <br /> __: <br /> 3. ❑,E COLATION TEST' <br /> �M <br /> r,. R.S. or R.G.E. No. <br /> R.S. os R.C.E i�fam2 i Test Date/Time ` <br /> Test LocationOtl <br /> q• ❑ SANITATION PER Q <br /> / } IFi <br /> Job Addre ocation r. <br /> Address E PLANT `I <br /> Owner ,� � 0 PACKAG , <br /> 11 SEPTIC TANK ❑ CESSPOOL a?e'LEACHING FIELD EPAGE PIT #, <br /> ERMANENT L—❑ TEMPORARY <br /> ❑ NEW { ❑ REPAIR -w ❑'OTHER ; <br /> 5. ❑ CHEMICALJOILETS For July i, -June 30, 19 <br /> Disposal Site <br /> Type Construction✓ <br /> tng Location(s) <br /> No. of Units r�rrr. Equipment Storage/Cleanis I� <br /> 6. ❑ PACKAGE T E TMENT PLANT For July 1, -June 30, 19 Where Certified �f <br /> Operator Name 1' C <br /> 1 Plant Locatlontr �I <br /> s y No. Units Served _ <br /> Plant Capacity _" : IX <br /> 7. C1 LAUNDRY For July 1, -June 30, 19 4 s n <br /> SIZE: 11 Le s Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 4 <br /> ll be done in <br /> I hereby certifyyFhat•l have prep ed this application Sanhakahe 'NLocal IHealth District,ccordance with San Joaq Yin Gotnty + <br /> ordinances, state,:laws, and' ul and -1 1 r r ; <br /> APPLICANT'S SIGN <br /> FOR DEPARTMENT USE ONLY <br /> ��-yy� ❑ January t &"Receiv B -ary 31 ❑ July i &:Received By July?$1 <br /> Fee Is Due: ❑ ANNUALLY E3 PER UNIT yatPER SITE. - EAC REMIT µ4 <br /> AMOUNT DUE CHECKED <br /> BILLING REMITTANCE <br /> Ij <br /> BASE,; EXPLANATION DATE TE R I D �`r�.- '�} AMOUNT I <br /> 'f ! I FEE I _ • <br /> LESS `R <br /> PRORATION <br /> PLUS ^<"..'--�.,• '� <br /> I PENALTY - "�.,,,� '�•,•�� <br /> OTHER <br /> OTHER <br /> " Is ante Date Mailed De1iv ed r <br /> Date Receipt No. :;! Permit No. - <br /> Received by -:� � �'e 1601 E.fiAZELTON AVE.,P.O.Box 2009 5T0 KION,GA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENYiRONMENTAL HEALTH PERMIT115ERYICES .F,t <br />