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+ Appy ) Prctces+ied when Submitted Property Completed.ft sure To, <br /> The dation. <br /> 4 T 'loft CATIQN <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTt# RMIT <br /> .LIgUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Dystrict <br /> r Business Nams4DBA) A dress <br /> l'- <br /> Owner Address ' <br /> #. <br /> Firm Partners, Addresses and, <br /> etephone Numbers <br /> Business Telephone No; Emergency Telephone No: <br /> j Contractor Licence No. <br /> 'Applicants Name jPrint *' '�` �"` ;' Titl '� -° Bate 3 <br /> Please check Applicable Category(1-7)and Fill Cithe Required Information <br /> 1. 13 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE), I <br /> For duly 1, June 30, 18Dlosalit <br /> Description(Make/Yr.,Color) �eL ae � - ,R � � <br /> Serial No. # CAL. License No. CAL.License Rer(ewai No. <br /> Cap ity ! Gal..Weights (Measures Na. <br /> Equip ent Parking Adds' i <br /> 2. EI7 PUMPER Y/RD <br /> For July 1,�,J 0 19_ 3 <br /> N of Vehicles <br /> No. f Chemical Tdilett Shared <br /> 3. PERCOLATION - <br /> -R.S.dCE.Name ' N.S.or R.C.E.No. ; <br /> Test Location ime <br /> 4.- SANITATI"PERMIT <br /> b Address/LocatIC,n <br /> Ow e,JKr - F�ddress ter, x <br /> SEPTIC TANK = ❑ CESSPOOL ,.WLEACHINd FIELD--A SEEPPjGEPIT a PACKAGE PLANTt <br /> PERMANENT ❑ TEMPORARY '�NE � REPAIR ❑OTHER 6 <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 3li,19 <br /> Type Constructions Disposal Site <br /> No.of Units _ Equipmenf Storage/Cleaning-Locations ' <br /> LJ ACKAGf 1 BEAT I T PLANT For July` ,-June 30. 1!I~ <br /> Operator Name "` Where-Certified <br /> Plant Location <br /> Plant Capacity . No. Units ` <br /> Sensed �`- <br /> 7. ❑ LAUNDRY"=For Jd#y 1,-June 30,19 = �` =• <br /> e , <br /> SIZE: .11 Less Than 1,000 Sq.-Ft„ 0;More Than 1,000 Sq. Ft. <br /> 13 DRY CLEANING,Chemicals UsedlAmount/Mo. <br /> I hereby certify that I have prepared this application and that the vrork will be,done in accordance with San Joaquin County <br /> ordinances,state laws,and rll and;regulaons ot4he San Joaquin'Local Health District. <br /> r. = <br /> APPLICANT'S SIGNATURE X '" <br /> FOR DEPARTMENT,USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑'EAGH ❑ January-1&Received By January 31` ❑July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION <br /> BILLING RE ITTANCE $ }tMOUNT DUE CHECKED <br /> ` <br /> DATE DATE REMITTED <br /> " ' "AMOUNT- <br /> FEE +•+.� <br /> LESS <br /> PRORATION _ <br /> PLUS - <br /> PENALTY s <br /> OTHER <br /> OTHER d <br /> A;o J97 <br /> Ric—eiil y Dater Receipt No, Permit No.71 Issuance pate ed Deq" <br /> A CANT`—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES' 16011 E.HAZELTON AVE t Ox 2008 :$�QN, 1118201"` .":,- <br />