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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> t (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> \\ ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE CJi <br /> Application is h e made to C ry on usine in the'uri di 'onal area of the San Joaquin Local Health Dist ' <br /> OF Business Name (DB ) Address � �' 76 <br /> z Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> IL IL Business Telephone No. `� �Q Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print, e,7- -a- Title V4(49 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 /> 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 /> 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 /> Test cation Test Date/Time —_ <br /> 4. SANITATION PERMIT <br /> Job Address/L cation '7137 eL7 <br /> Owner , Adt ress -� <br /> ❑ SEPTIC TANK ❑ CESSPOOL ELEACHING FIELD'i ❑ PACKAGE PLANT Z <br /> UPERMANENT ❑ TEMPORARY ❑ NEW M-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) a <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June=30„#9 ' <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' `^s <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 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 laws,and r es and regulations o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Ity Pa <br /> FOR DEPARTMENT USE ONz <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ Janus Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING I CE $ AMOUNT DUE CHECKED <br /> DATE ATE REMITTED AMOUNT <br /> 000, <br /> y/ <br /> FEE L”. <br /> LESS <br /> PRORATION VV <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Irver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZEL N AV�P.O.B 2009 QSTTOC ON,CA 5201 <br /> j�'�/9/X�7�AA�C/J <br />