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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION / <br /> (For Non-TransfeMbi , Revocable,and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WANE 1 <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,,Business Name (DBA) Tri CniL''tty Lu1ldeYs, inc. .- Address P.O. Box 44&3, ��desto, CA 95352 f <br /> r nn�a,�., .rare �irouwer,R.Vande Kieftp,ddress P•0• B . 4463restOa 95352 <br /> z Owner - <br /> 2 Firm Partners, Addresses and Telephone Numbers k <br /> IL 209 . 521-7443 .Emergency Telephone No. <br /> M Business Telephone No. - <br /> Contractor Licence No. 2 5778 -° 12/10 81 I <br /> Yl tIn U11 r President .Date <br /> L Applicants Name(Print) Title : v <br /> Please check Applicable Category (1-7) and Fill in a Required In ormation { it- <br /> 1. <br /> t1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1., June 30, 19 - Disposal Sites <br /> Description(Mak_a/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity "' — Gal.7 Weights & Measures No-- <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD i <br /> For July 1, ` June 30, 19 <br /> a <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.G.E. Name. R.S. or R.C.E. No. <br /> Xdress/LocafionL <br /> Test Date/Time <br /> ''4. SANITATION PERMITJo ' ' St.High4 Stockton <br /> '� _. "` A address East Hi 1_V7a E4., Stockton CA <br /> Owner" I <br /> SEPTIC TANK 11 CESSPOOL CESSPOOLy.�. LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT ` <br /> ❑ PERMANENT' ❑"TEMPORARY 4.k� NEWy. ❑ REPAIR 13 OTHER <br /> 5. 13CHEMICAL:TOILETS For July 1, =June 30Axk <br /> 19- <br /> Type Construction A .y}` .&�Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Naive <br /> Plant Location r <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 T <br /> SIZE:, ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DF�{tY CLEANING,Chemicals Used/Amount/Mo. <br /> tiamaownarorlicensedagent'ssignatureceri,iFsttlafalFawing:"I ced;fr thatn ftte performance of thetvorkfor whOTthis permit is issued,Ishall notemploy any person <br /> in such manner as to became sub;ect to wur€cm;ail'S compeiratinn fauns of Ca.itortia." <br /> Contractors hiring or sub-contracting aigneturo cerdfles the tattuwing. "1 certify Mat in tho performance of the work for which this permit is issued,t shall <br /> emlzlay persons sublixt to workman's compensation,laws of Calitornia." <br /> I hereby certify that I have prepared ythis vapplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules a re ulati ns of h San Joa uin I Health Distric <br /> APPLICANT'S SIGNATURE X <br /> r.r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due' ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH f L❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> 4 -7 REMIT <br /> BILLING-00' REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE * DATE REMITTED AMOUNT <br /> FEE <br /> LESS * t <br /> r PRORATION 1r / <br /> PLUS tI <br /> PENALTY - � <br /> OTHER <br /> OTHER <br /> 75, <br /> Received b Da Receipt No. Permit No. Issuance Hate Mailed Deliv red / <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL_HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O."BOM 2009- STO, KTON,C 95201 <br /> r <br />