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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 /> Application is reby made to c rryon business in the' risdictional area of the San Joaquin Local Health strict <br /> Business Name (DB Address /S <br /> i Owner Address <br /> a - <br /> J Firm Partners, Addresses and Telephone Numbers <br /> K Business Telephone No. g -�� Emergency Telephone No. <br /> j Contractor Licence No. L-2— <br /> LApplicants'Name.(Print).�i Title Date <br /> Please check Applicable Category (1-7) and Fill in the Require Information <br /> -1.- 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For""July 1, June 30,=19 Disposal Sites <br /> Description(Make/Yr., Color) W <br /> Serial No. : CAL. License No. CAL. License Renewal No. <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 Stored — <br /> I <br /> i No. of Chemical Toilets Stored ; <br /> 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E. Name R.S. or R.C.E.No. ' S <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT 1 <br /> Job AdZ—ANK-10 <br /> Locat �� t.0 t� t <br /> Owner <br /> 6-e .1�� Address <br /> ❑ SEPCESSPOOL ❑ LEACHING FIELDIT ❑ PACKAGE PLANT <br /> ❑ 11 <br /> ❑ PERMANENT TEMPORARY NEW REPAIR E ❑ OTHER 47 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 I t <br /> Type Construction Disposal Site G <br /> No. of Units Equipment Storage/Gleaning Location(s) AIQ <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity Na. Units Served <br /> 7. ❑ LAUNDRY For July 1 Mine 30, 19 _ <br /> SIZE: ❑ Less Than 1,000 Sq. Ftp--- ❑ More+Than,1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. ) <br /> r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state lav+s'and-rules-and--galations of the S nJoaquin Local Health District. <br /> APPLICANT'S SIGNATURE X_?- <br /> r <br /> I <br /> FOR DEPARTMENT USE ONLY I <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION " BILLING REMITTANCE $ AMOUNT DUE CHECKED . <br /> Jt ..3' DATE DATE REMITTED I AMOUNT <br /> FEE <br /> LESS 1 1 <br /> PRORATION i - <br /> PLUS <br /> PENALTY <br /> OTHER 1 Ro 2► <br /> S <br /> OTHER <br /> INM <br /> Received by Date Receipt No. Permit No. Issuan9d Effle I <br /> ai d Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - 1601 E.'HAZELTON AVE., c 2009 STOCKTON,CA 95201 <br /> C <br />