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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. j�cj_ Zou_ S <br /> APPLICA ON k <br /> (For Non-Transferable, Revocable, d Suspendable) <br /> ENVIRONMENTAL HEALT PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Applicati in�i's hereby made to carry on business in the juris tonal area of he uln Lo ealth Dist <br /> F Business Name (DBA) ! ' /Al ,�_ -� i%j Address <br /> a Owner .:pC'�!.�'¢�y�'� � Address <br /> - z <br /> Firm Partners, Addresses and Telephon� e Numb � %7'�/-- <br /> 0. Business Telephone No., f J� `� Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants Name (Print)t <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 rn <br /> Description(Make/Yr., Color) <br /> Serial No CA . Li n No. _ CAL. License Renewal No. <br /> Capacity Gal.,t4_ zol sures No. <br /> Equipme t P rking Address 01 <br /> 2. ❑ Pl.MP R YARD <br /> For July June 30, 19 <br /> No. of V icl s Stored <br /> No. of C mi a (lets Stored <br /> 3. IEDP RC L_ ON TEST <br /> R.S. or R. .E. N R.S. or R.C.E.No. �1 <br /> Test Loc io Test Date/Time <br /> 4. ❑ S I N PERMIT + / <br /> Job Addr ss/ ocatio <br /> Own Address <br /> USEP N PO LE= 1:1G FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> PE N NT �O AR NEW 11 REPAIR ❑ OTHER x ,r' Y - <br /> 5. ❑ C EM C [LETS s 'r 4Wy 1;•. June 30, 1j J i 1 <br /> Type str tion C'�...L�*awlte <br /> s_�,_A No. of its Equipment Storage/Cleaning Location(s) <br /> 6."-� P CK E TQEATMENT PLA T r ul �une 30, 19 <br /> Ope ,an a Where Certified <br /> t7j__:�: <br /> Plant do <br /> Plan acill Units r e <br /> jN <br /> 7. ❑ LP LIN RY For July 1 e 30 1 ' <br /> SIZE: ess Than 1,000 "Ft., MdQhAe.Q00 S <br /> ❑ DRY E NTNG,Chem icals,Lii6d%Amount/Mo. > <br /> i <br /> I ereby cert if that I have prepared this application and that the work will be done in accordance wit ;San Joaquin County <br /> or inar s, s to laws, an aulati s of the San Joa ' i. Local Health District. <br /> APPLICA qT SIC NATL Rr <br /> FOR DEPARTMENT USE ONLY <br /> Fe IS ue: ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Rec`eived By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FE ' y' <br /> LE <br /> PR RAT ON <br /> PLLS <br /> PE ALT <br /> OT ER <br /> OT ER <br /> ' .� / <br /> Re ive by Date Rece �o. ermit No. Issuance Date Mailed ,, De i eyed <br /> PLI ANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009P STOCKTON,CA 95201 <br />