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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) I <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i eby madEpo carry on sines in th ' ' 'ctional area of the Sa oaqul Local Health Distric 0 <br /> NBusiness Name A) - Address ? <br /> i Owner Address <br /> a <br /> J.Firm Partners, Addresses and Telephone Numbers <br /> IL <br /> Emergency Telephone No. <br /> 0. Business Telephone No. <br /> Contractor Licence No. <br /> a Title gate <br /> L Applicants Name (Print) ; <br /> s <br /> Please Check Applicable,Category (1-7)and Fill In the Required Informa ion <br /> 1. ❑ PUMPER'VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July, June€30,:,19 Disposal Sites <br /> Description(Make/Yr.�Color}= - <br /> Serial No, l CAL. License No. CAL. License Renewal No. ! <br /> Y <br /> Ca acit ; Gal., Weights & Measures No. I <br /> Capacity i <br /> Equipment Parking Address_' I <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19: <br /> No. of Vehicles Stored I <br /> f No. of Chemical Toilets Stored$ <br /> 3. /R .E. <br /> OLATION TEST <br /> R.S. Name R.S. or R.C.E. No.TesnTest Dake/Time <br /> 4. TATION PERMIT <br /> Job Addre ation -6 2 /j <br /> O�w�r Address Z 1,4z r3I <br /> f LA'S TI TANK 1:1CESSPOOL L CHING FIELD SEEPAGE PIT 0 PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER ^� <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 r I <br /> Type Construction Disposal Site i <br /> No. of Units Equipment Storage/Cleanirig Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 j <br /> Operator Name <br /> Where Certified i <br /> � # � <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> i <br /> 7. ❑ LAUNDRY For July 1,405une 30, 19 f { <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., C3 More Than 1,000 Sq. X <br /> ❑ DRY CLEANING, Chemicals.Used/Amount/Mo. <br /> +►�c 4A <br /> I hereby certify that I have prepar �is application and that the,wbPk will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rule n egulations the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 4 ff <br /> ;f <br /> FOR DEPARTMENT USE ONLY <br /> I 'Fee Is Due: ❑ ANNUALLY ❑ PER UNIT .PER SITE ❑ EACH ❑ January 1 &Received By January 31, ❑ July 1 &Received By July 31 <br /> REMIT <br />} f 'BILLING. REMITTANCE 'AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> � AMOUNT <br /> LFEE i� <br /> LESS <br /> PRORATION d <br /> PLUS <br /> PENALTY <br /> OTHER <br /> ,I F <br /> OTHER <br /> \ I, TM Received by Date Receipt No. Permit No. Issuance Date Mailed - e ere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH-PERMIT/SERVICES 1601 E.HAZELTON P.O.Boll 2 09 STOC ON,GA 95 01 <br /> „� AVE.,x2p /, a <br />