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m <br /> Applications Will Be Processed When Submitted Properly Compieted`ale Sure To Sign The Application. <br /> APfICATION <br /> `P x (For Nom! Rerocabfis,and Suspendable) SEPTAGE <br /> �/ ENVIRONMENTAL HEALTH PERMIT S 1(j�ED +CppY <br /> O UQtNII WASTE <br /> Application isre(�, ,madameE t car busir►ess ir6 iurisdictlonal ajraea of th ul(�Lo salt t <br /> Business Name (DBA) ��,`s — 'ls liic(dreals JF -� <br /> Owner Address <br /> Firm Partners, Addresses andBone N9m ers,�_1 <br /> Business Telephone No. � (GJQ / Emergency Telepbone No. <br /> Contractor Licence:No., <br /> Applicants Name(Print) �,+ Title r <br /> Please check Applicable Category ty T41rld Fill In the Required Information ^i <br /> v <br /> 1. ❑ PUMPERVEHICLE PERMIT R90tSTRATiON(FOR EACH VlffibCLE W <br /> For"July 1, June 30, 19 Disposal Sites` <br /> Description(Make/Yr.; Cdlor) - <br /> Seriat•No. CAS,.License No., CAL. License'Renewsi No. <br /> Capacity Gal.,Weig#►ts'&Measures No. <br /> Equipment Parking Address. <br /> 2. ❑ PUMPER YARD <br /> For July t,< June 30, 1g <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 Location Test Date/Time ' <br /> 4. SANITATION PE T <br /> Job Addr s/Locati n <br /> fer Address<:EPTICTANK ❑ CESSPOOL LEACHING FIELD -16 SEEPAGE PiT 11 PACKAGE PLANTERMANENT 0 TEMPORARyr 9 ❑ OTHER-NEW REPAIR ...� <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site -� <br /> No. of Units Equipment Storage/Cleaning Locatigp(s) <br /> 6. 0 PACKAGE TREATMENT PLANT ForJuly 1,-June 30,19 <br /> ;.. Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July, 1 -June 33 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., `b More Than 1,000 Sq.-ft <br /> 0 DRY CLEANING;Chemicals Used/Amount/Mo. <br /> I'herdby certify that I have prepared this applotibn and that the work will be done in'_accordance with San Joaquin County <br /> ordipances,state laws,and rules•and Kegulations,of n Joaquin Local Health District. <br /> APPLICAN r,"IGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: 0 ANNUALLY `--0 PER1}NIT Q,PER SITE - ❑ EACH ❑ January i,&Received By January 31 ❑ JdTy,1 &Received By July 31 �. <br /> REMIT <br /> BILLING REMITTANCE $BASE NATION AMOUNT QUE CHECKED <br /> #. <br /> DIVE,__ DATE REMITTED AMOUNT <br /> FEE <br /> _ LESS <br /> PRORATI <br /> PLUSor _ <br /> PENALTY <br /> OTHER-,- <br /> 1 <br /> flT , <br /> Received by Date Receipt wo: Perrr�T♦No. ' 1 an a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO. ENVIRONNIgNtAL HEALt#PXR111T/SbfflCFgS 1601 E.HAnLTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> s <br />