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Applications Will Be Processed When Submitted,Properly Completed. BeSure iosign IneHppucatwrr. <br /> APPLICATION <br /> r (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional area of the Sant oa uin LocaHealth District <br /> N Business Name (DBA) . — 4 c.r Address <br /> ! a <br /> z Owner F Address <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> 0.a Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. C} <br /> LApplicants Name{Print) Title - Date— --�� <br /> Please check Applicable Category (1-7) 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) _ <br /> Serial No. f CAL. License No. CAL. 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 To lets Stored <br /> 3. ❑ PERCOLATION TEST f <br /> ^� or R.C.E. No. <br /> R.S. or R.C.E. Nama. � R.S. , <br /> ' <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT94t= ,J , <br /> Job Address/Location CA <br /> O�w�n..e�^r„ Address <br /> L•TSEPTIC:TANK -CESSPOOL �CHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑TEMPORARY NEW 11 REPAIR 11 OTHER <br /> 5. ❑ CHEMICAL TOILETS, Fo�_July 1,-June <br /> Type Construction Disposal Site , 0 <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July�1,''June 30, 19 Y '. <br /> SIZE: 1:31 Less Than 1,000 S0F4t- <br /> C1 More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - - <br /> I hereby certify that I have prepared,this appanlication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state:laws d rules and �tions of the Sari Joaquin Local Health District. <br /> 1•r � <br /> APPLICANT'S SIGNATURE X <br /> ., _ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY. PER UNIT u I'tR$IT.E ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE 'REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt Na- <br /> Permit No. Issuance Date Mailed Delivered <br /> , O <br /> O.Box 2009 ST6CKT0 CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITJSERVICES 1681 E.HAZELTON AVE.,P- , <br /> y. e w <br />