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CSO ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> I ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is b made t r o bu/�lness in the jurisdictional area of the San Joaquin Local Health DJ'stri <br /> w Business Name (DBA D(1� r� Address / a <br /> a 7S <br /> Owner � t.�� Address AV <br /> J Firm Partners, Addresses and Telephone Numbers <br /> Q.a Business Telephone No. G Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name Name (Print) v Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information o <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites i <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 PERMIT <br /> Job Address ocatioOwnerAddress <br /> Address <br /> SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW -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) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. 11 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 /> i <br /> I hereby certify that I have ed ' ap Icatio and at the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rul egu ions O the n Joaqui ocal Health Dis ict. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 6 Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCEREMIT <br /> $ ADUE CHECKED <br /> DATE DATE REMITTED MOUNT <br /> FEE4 ' 1 u AMOUNT <br /> LESS / <br /> PRORATION / <br /> PLUS <br /> PENALTY i <br /> OTHER <br /> y <br /> OTHER <br /> ti <br /> Received by Date Permit N- <br /> Receipt No. o. IissuandeDate Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOC TON,CA 95201 <br />