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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) <br /> ' ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> r� ' �r b- rP� LIQUID WASTE C107- Y 00-Caf <br /> Application is ereby made to arty on business in the urisdictional area of the San Joaquin Local Health Distric <br /> wBusiness Name (Q8 - �•" A dress Ze 7 <br /> z Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> a -Telephone No.—.- d S _ Emergency Telephone No. <br /> Contractor Licence No. �d q <br /> Applicants Name (Print) Titie Date �E' �� 7r <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. CAL. License No. CAL. Licznse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address :fl <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 O <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 /> Test Location Test Date/Time <br /> i 4. ❑ SANITATION PER I Gam- d <br /> Job Address/Location <br /> Owr Address 5 <br /> L'APTIC TANK ❑ CESSPOOL -ACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT t <br /> 15 PERMANENT 13 TEMPORARY NEW ❑ REPAIR ❑ OTHER �sQ <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 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served , <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules regulations of the SanJoaquin Local Health District. <br /> k s <br /> APPLICANT'S SIGNATURE X <br /> a <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &.Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> i BASE EXPLANATION DATE PATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> k FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> ca <br /> 77-9 9 1 d 11 7 <br /> Received by Dale receipt N. Permit No. Issuance Date Mailed Delivere <br /> - APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.H ZEL ON AVE.,P.4?.Box 2009- STOCK N CA 95201 <br />