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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 herby ade t ry on usiness in the jurisdictional area of the Sag,loa�ui cal Health Distri tt <br /> y Business Name DB ) Addre s �"' l/ d <br /> aOwner ° Address �s--� <br /> 2 Firm Partner , ddresses and Telephone Numbers <br /> a. Business Telephone No. G Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants NamTitle Lis 6` I;.,�,A01- Date �J <br /> Please check Applicable Category(1-7)and Fill in th Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> l <br /> For July 1, June 30, 19 Disposal Sites �- <br /> Description(Make/Yr.,Color) -4- <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights &Measures No. <br /> EquipmentParking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19� _ <br /> No. of Vehic(pi_`Stored <br /> No. of Chemical Toilets <br /> 3. ❑ PERCOLATION 344 } a t } <br /> R.S.or R.C.E. Name + R.S. or R.C.E. No. , <br /> Test ocation Test nate/Time <br /> 4. �SANITATION PERMIT <br /> Job Address/ cation �'z% <br /> If I <br /> kSErPRIVIANENT <br /> Dom' Address e <br /> C TANK ❑ CESSPOL LEACHI FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ TEIdI 6+ ARYq tjAff< REPAIR ❑ OTHER ` Q <br /> 5. ❑ CHEMICAL TOILETS For Jul <br /> y , -June 30,".79 '°- <br /> Type Construction I Disposal Site <br /> No. of Units Equipment ttorage/Cleaning Loca. <br /> 6. ❑ PACKAGE'TREATMENT OLAN I For July 1,1-June 30, 19 } 3✓' I <br /> Operator Name I t, Where CertUV'.. <br /> Plant Location <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.; ❑ More Thon 1,000 Sq. Ft. j <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> j ( <br /> S <br /> I hereby certify that I have prepared thi application and that the work will be do a in accordance with San Joaquirrt ounty <br /> ordinances, state laws, and rul d regulations of the San Joaquin Local Heal istrict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ! <br /> •Q EACH January 1 8 'ceived By January 31 ❑ Ju' 1 8 Receivr!d By July 81 <br /> ...__.. „.. ..,. REMIT <br /> BILLING REMITTANCE i $ I <br /> BASE; EXPLANATION AMOUNT DUE CHECKED , <br /> DATE DATE ;REMITTED AMOUNT ' <br /> FEEiv\ <br /> LESS i <br /> PRORATION <br /> PLUS /y L <br /> PENALTY /J <br /> OTHER Q <br /> OTHER S <br /> Received by Date Receipt o. Permit No. Idsuancd Date Mailed Delivered <br /> APPLICANT-RETURN ALL COPIES TO: ENVIRONMgNTAL HEALTH PERMIT/SERVICES •1601 a°.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />