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Applications Will Be Processed When Submitted Properly Complete a sure <br /> APPLICATION <br /> .(For Non-Transferable, Revocable;and Suspendable) SEPTAGE 1 i <br /> y - ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> N Business Name (DBA) TACDO>'13ld <br /> Address4645 Hildrnth _Laxl�e_ <br /> a Owner T . R. MCD na ��Ad=res � <br /> P <br /> Firm Partners, Addresses and TelephoneNumbers <br /> a Business Telephone No.93 —�y 7 } Emergency Telephone No, 9t <br /> a ( vn <br /> �Contractor Licence No. 3081. 7 1 Title --�r�g�' Date <br /> Applicants Name (Print)T. R• CD - VA <br /> j Please check Applicable Category(1-7) and Fill in the Required Information r� <br /> 1. ❑ PUMPER'VEHICLE.PERIVIIT REGISTRATION.(FOR EACH VEHICLE) ' <br /> For July 1, , June 30, 19 ' <br /> � -„� Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> 'l Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> i For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST # R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location ( /u Gt '51 'J Q <br /> 4. ❑ SANITATION PERMIT Q <br /> Job Addre q4LocAtion <br /> � ess \ <br /> fOwner t ❑ PACKAGE PLANT <br /> ISEPTIC TANK❑YCESSPOQLR-�^-+� - EACf11NG l LD � REPAIR E P17 11 OTHER <br /> F ❑ PERMANENT ❑ TEMPORARY <br /> CHEMICAL <br /> } <br /> hf 5. ❑ CHEMICAL TOILETS For July 1;-June 30, 19 <br /> Type Construction wx�'"'. Disposal Site <br /> t No. of Units Equipment Storage/Cle aning Location(s) <br /> 6. 13 PACKAGE TREATMENT PLANT For July 1, -June 34, 19 <br /> ,cn Where Certified <br /> Operator Name 1 <br /> Plant Location �. <br /> Plant Capacity �J U>No."Llnits Served <br /> I <br /> 7. ❑;LAUNDRY For July 1, -June 30,19 y <br /> SIZE:1 ❑ Less Than 1,000 Sq.`Ft' El More Than 1000�S t. ' <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. 11 � <br /> 1 s,- <br /> ` �•i } .�� ace ,dance with Sa J Lin ounty <br /> )I <br /> I hereby certify that I have prepared this application and that the work will be done In / <br /> G ordinances, state law`s and ruI an regulat I 'rof the San Joaquin Lo I Health District. , �l <br /> ✓i <br /> I APPLICANT'S SIGNATURE X <br /> a a <br /> FOR DEPAA MENT USE ONLY <br /> Fee Is Due' 13 ANNUALLY ❑ PER UNIT ❑ PERq SITE _❑-EACH ❑ January l &Receiv d B Jan a y 3 July 1 &Receiv REMIT <br /> d By uIy 37 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> I BASE EXPLANATION Et DATE DATE - MIT ED AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> l OTHER <br /> Received by `h []ate Receipt No. <br /> Permit No. is uance Date Mailed Delivered <br /> 1501 E.HAZELTON AVE.;P.O.Box 2009 STOCKTON,CA 95201 . <br /> ¢� APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />