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Applications Will Be Processed When Submitted Properly omp e e t <br /> APPLICATION <br /> (For Non-Transferable;Revocable;and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> \Application i r y ma t car on b iness in the jurisdictional area of the Sao n�cal H th Di I t <br /> Address - i J ,(,�✓ <br /> rn Business Nam B <br /> a Owner Address y+ <br /> 1 <br /> 0- Firm Partne , Addresses and T le one bers Emergency Telephone No, _ <br /> 0. Business Telephone.No. _ ' _ ` <br /> Contractor Licence No. -`� �` W <br /> { /1<. Title <br /> °� Date <br /> L Applicants IName (Print) M1 <br /> Please check Applicable Category 1_-7) and,- -l,04he Required1lnformation s ��a z(�, t a 2 x Vl_1 <br /> For PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> -Disposal Sites—i I- <br /> -For 30, 19—'— <br /> Descrlpti -n(Make/Yr,, Color) AL't66ense'Renewai'N6. <br /> Serial No. <br /> CAL. License No. <br /> r <br /> Capacity Gal., Weights Measures No. <br /> Equipment Parking Address 4.4 ,� . <br /> 2. 11 PUMPER YARD] �� # <br /> For July 1, June 30, 19 + — T <br /> l -No. of Vehicles Stored <br /> No. of Chemical Toilets Stored F <br /> I 3. ❑ PERCOLATION TEST <br /> R.S. or R.C:E. No. _. <br /> .R.S. or R.C.E. NameF <br /> TesY ' Test Date/Time <br /> Lo On, t <br /> Art - <br /> 4. SANITATION PERMIT ®03 <br /> Job Addres ocati <br /> Owner Address <br /> RING FIELD L'S SEEPAGE PIT I'❑'QAC KAGE`PL'ANT-�"""""�""" <br /> EPTIC TANK ❑ C POOL ❑ REPALR ❑ OTHER <br /> .❑ PERMANENTTEMPORARY NEW <br /> I 5. <br /> 11 CHEMICALTOILETS For July 1,-June 30, 19 . :O <br /> Type Construction Disposal Site <br /> of UnitsEquipment Storage/Cleaning Location(s) <br /> f. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> } T L Where Certified ' <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity t <br /> 7. Cl LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ff DRY CLEANING, Chemicals Used/Amount/Mo. v <br /> (, ._ { , <br /> Thereby certify that i have prepared this application and that thew <br /> will be done in accordance with San oaquin 4- <br /> County <br /> ordinances,state laws, and r nd regulatio s of the an Joaquin Local Health_ District. <br /> APPLICANT'S SIGNATURE X T <br /> f - ; <br /> FOR DEPARTMENT-USE ONLY <br /> _ Fee Is Due: [3 ANNUALLY ❑ PER UNIT ❑ PER SITE C1 EACH ❑ January 1 &Received By.fanuary 31 ❑ Juiy 1 &Received July 31 <br /> REMIT <br /> BILLING _ REMITTANCE AMOUNT DUE CHECKED <br /> BAS_E EXPLANATIQN DATE ATE _ - RE D AMOUNT <br /> F FEE <br /> LESS <br /> PRORATION <br /> P US <br /> PENALTY � {�+ <br /> OTHER r rl - i <br /> •§!� <br /> OTHER <br /> y�V,9 � Marled Delivered <br /> e < " r Permit No. I a e b a _` <br /> Received by Date Receipt No <br /> .�„ .a-e- ... <br /> 4''r" �'(1601 E HAZELTON AYE.,P.O.1301 2004 ST OCKTON.' 952at <br /> °APPLICANT—RETURN A L COPIES TO: J ENVIRONMENTpI.HEALTHERM{T/5ERYICES^r I � <br />