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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 /> 71- ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati� ereby m e to carry osmess in the jurisdictional area of the San JoagLyn Lol Di trict <br /> y Business Name (DBA)(' 1�Ate LZAW, Address, <br /> z Owner Address <br /> C <br /> L Firm Partners,Addresses and T p one um ers <br /> a. Business Telephone No. — � Emergency Telephone No. <br /> Contractor Licence No. G <br /> � <br /> Applicants Name (Print) l Title 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 Location } Test Date/Time <br /> 4. ❑ SANITATION PERM _ y,• <br /> Job Addre cation i Imo. '^ <br /> Owner Address <br /> 'SEPTIC TANK ❑ CESSPOOLrEA6HING FIELD 9 E' AGE PIT 0 PACKAGE PLANT <br /> �_RMANENT 1:1 TEMPORARY ®'I�EW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1, -June 30,19 <br /> Type Construction Disp sal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1„-June 36'_19',` <br /> Operator Name Where Certified <br /> Plant Location U <br /> Plant Capacity No. Units Served I <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> _ 1 <br /> I hereby certify that I hav/e/pped is.appliation a h he work willbe done in accordance with San Joaquin County <br /> ordinances,state I s, anation#;of Jo qu' Health District. <br /> APPLICANT'S SIGNATURE.. •// s <br /> FOR DEPARTMENT A6EONI=Y-- <br /> Fee Is Due: ❑ ANNUALLY ❑PER UNIT Q PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION t AMOUNT DUE CHECKED <br /> PATE DATE REMITTED AMOUNT <br /> FEE t <br /> f <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY <br /> OTHER <br /> OTHER a <br /> - b-a-` 4) <br /> Received by Date Receipt No. Permit No. Issuance Date iled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAV'.,P.0-18..2009 STOCKTON,.CA 95201 <br />