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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. „ �] <br /> APPLICATION - -- - -y <br /> (For Non Transferable, Revocable,and Suspendable) SErPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT J} <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) BANTA SCHOOL DISTRICT Address 22345 S. El Rancho. Road Trac Ca. <br /> z Owner Banta School District Address 22345. S. E1 Rancho Road Trac Ca. 95376 <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. 835--0171 Emergency Telephone No. <br /> a <br /> J Contractor Licence No. Banta School District Applicants Name (Print) Ban <br /> __ ___ pate Oct. 1,5„ 1979 <br /> ta School District Title <br /> Please check Applicable Category (1-7)and Fill in the Required Inlormation W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 _ Disposal Sites h� <br /> Description(Make/Yr., Color) <br /> Serial No, CAL. License No. CAL. License Renewal No. <br /> Capacity <br /> 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 /> s <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 22345 S. El Rancho Road, Tracy, . Ca. .•- 95376 <br /> Owner <br /> Banta School District Address Same <br /> X SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY NEW ❑ REPAIR 11. 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 i <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 f <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo: <br /> a <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqn County <br />` ordinances, state law nd ruies and r Mations of th=SanJoaquin Local Ha Di trict. <br /> APPLICANT'S SIGNATURE X <br /> I� FOR DEPARTMENT USE ONLY <br /> Fee Is Due: El ANNUALLY ❑ PER UNIT PER SITE 11 EACH 11 January 1 &Received By January 31 ❑ July 1 &ReceiveM�r.,riy 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED s ,r AMOUNT <br /> FEE . <br /> LESS r <br /> PRORATION <br /> PLUS - <br /> ° PENALTY - <br /> OTHER co " <br /> t <br /> OTHER <br /> -7 1 10 7 <br /> (. Received by Date Receipt No. Permit No. Issuance Date Mailed d - <br /> fl <br /> ' APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Bax 2009 570C O GA 5 1 - <br /> � „ <br />