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.�. Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> - % APPLICATION _ <br /> ZF <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGEENVIRONMENTAL HEALTH PERMIT <br /> LIQtlID WASTE Application is heereby�m�ade to carry o. business in the jurisdictional area of the San Joaquin L I Health District 00 -BusnessName BA) � r—>I 1�`" n e!�C r V j Ce--— Address ����RI ���'`�� <br /> aOwner V� �'` Address 11-3719 i �r1a.�t <br /> Firm Partners, Addresses and Telephone NumbersV <br /> a `y Emergency Telephone No. <br /> CL Business Telephone No. <br /> Contractor Licence No. � * d <br /> Applicants Name (Print) V e � $�� Title 0_.7a"-�—/L� 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 /> r Description(Make/Yr.;Color) <br /> I <br /> e Serial No. CAL. License No: CAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. _ <br /> F � <br /> f Equipment Parking Address <br /> 2. ❑ PUMPER YARD : <br /> i <br /> For July 1, June 30, 19 ` <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored } <br /> i 3. D PERCOLATION TEST <br /> r <br /> I R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT //l <br /> r Job Address/tation - <br /> E O ner ah � ry Address ti � _ <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLANT ,�Q eGf-r / <br /> 13 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR OTHER d—f <br />` ? S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> s Type Construction ­Disposif ite <br /> U ty" <br /> No. of Units Equipment Storage/Cleaning Location(s) � <br /> B. ❑ 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 /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby certify that I have prep a is application and th t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and ruL4,u4reguiationyof,t6 a Joaquin Local Health District. <br /> r <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY < <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT, 0.PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juty 31 <br /> REMIT I <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED e <br /> DATE DATE REMITTED AMOUNT <br /> FEE S 7 <br /> ILESSL ! O <br /> ± PRORATION <br /> PLUS r�ZvY3r <br /> PENALTY <br /> I <br /> OTHER <br /> OTHER � <br /> _ _.Received by . �...d.-..-Receipt.Nu. _ " s_. �' Permit No. _ -.,,.Is uance ate— -Mailed�� ,,pgelivered_ <br /> APPLICANT—RETURN.ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES t601 E.HAZELTON AVE.,P.O.Bos 2009 STOCKTON,CPL_7$w1*_ <br />