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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignTheApplication. <br /> 'w -- APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> o bots cv�"1CtG-F-Gwr- LIQUID WASTE l2y_/ q�_S� <br /> re" i ad to-carry on business in the urisdictional area of the San Joaquin <br /> Applicaal H alth District r <br /> rn Business Name (D ) 4 J"E!r'Ul��' Address '-" _ <br /> aOwner,,t � r Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL G Emergency Telephone No- <br /> a. <br /> o. <br /> a. Business Telephone No. <br /> Contractor Licence—No. <br /> L Applicants 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(MakeNr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD O <br /> For July 1, June 30, 19 <br /> e <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 /> 4. A SANITATION PERMIT # +� R � � 110 U <br /> Job Address/Location <br /> Owner fS/}s/y(tlfT�% OJ�CST �a� Address A SGI �� <br /> X SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> Equipment Stora Storage/Cleaning Location s)` V <br /> No. of Units9 g (. _ Ls <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 <br /> SIZE: ❑ Less Than 1,004 Sq. Ft., ❑ More Than 1,000 Sq, Ft. <br /> 11 DRY CLEANING, Chemicals Used/Amount/Mo. 'k <br /> I hereby certify th pared this application and that the work will be done in accordance-with San Joaquin County <br /> ordinances, stat aws, a �regulationn� of the "n Joaquin Local Health District. <br /> n <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Dile: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASF EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> L� <br /> FEE <br /> LESS <br /> PRORATION r <br /> PLUS <br /> PENALTY <br /> o,,rd <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed ere F ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT'/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKT N,CA 9 201 <br /> t? <br />