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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) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> r Applicatio is hereby de to carrya�n busine s in the jurisdictional area of the S Joa in Lo al Hea District <br /> �Business ame (DBA) �r, <br /> - Addres aOwner AY <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CIL .35 3 Emergency Telephone No. <br /> E Business Telephone No. — <br /> Contractor Licence No. . �- <br /> L Applicants Name (Print)—r� L £� —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(Make/Yr., Color) <br /> j Serial No. CAL. License No. CAL. License Renewal No. <br /> i <br /> Capacity Gal.,Weights & Measures No, <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stared <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 /> Testi Lo ation Test Date/Time <br /> 4. L SANITATION PER IT <br /> g It <br /> Job Address/ cation Ap S -- -_ <br /> Owner i Address x <br /> LrSE TIC TANK ❑ CESSPOOL 24'LEACHING FIELD &-SEEPAGE PIT ❑ PACKAGE PLANT <br /> UPERMANENT ❑ TEMPORARY EINEW REPAIR ❑ OTHER <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 /> k Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July i, -June 30, 19 <br /> 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 applicati and th t the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul re lations a Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ RNNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ Jury 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> S c Sys <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ]� <br /> Received by Dale Receipt No. Permit No. Issua ce Dae Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 S OCKTO CA 95201 <br />