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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 /> ENVIRONMENTAL HEALTH PERMIT <br /> I/ LIQUID WASTE �, 4 <br /> y f <br /> Application is hereby made to carry o business in the jurisdictional area_of the San Joaquin Local Health District <br /> y Business Name (DBA), _�._-.1�J��f? I�a_jy SO/lU - AJC- Address PQ•t-`�k tyfRO Ifjo, Gam" <br /> z Owner Address „ <br /> Firm Partners, Addresses and Telephone Numbers <br /> OL <br /> Business Telephone No. Emergency-_- Emergency Telephone No. u <br /> Contractor Licence No. 2 � � - <br /> r Applicants Name (Print) STA?­) Title.- Date,l <br /> Please check Applicable Category (1-7) and Fill in 4he Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) I <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 r r <br /> 2. ❑ PUMPER YARD "# <br /> For July 1, ` m June 30, 19 <br /> No. of Vehicles Stored ( _No. of of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST I <br /> R.S.or R.C.E. Name - _s ►� tom•:,. �. �,- �. R.S. or'RfC.E. Na �• <br /> Test LL ation `"Test Date/Time'- <br /> t 4. 61 SANITATION PERMITS <br /> Job Address/Location lka �� x : y i� t' _"�` <br /> Own C—rAV 1 N ! M S Address -S <br /> SEPE] -•-TIC TANK CESSPOOL- C,-�/E . <br /> ACHING FIELD.. '❑ SEEPAGE PITt�`'° ❑ PACKAGE: PLANT <br /> p N"PERMANENT 11 TEMPORARY""10 51 NEW '"-C] REPAIR 41 ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS. For July 1, -June 30, 19 Iy v <br /> 6' <br /> { Type Construction - Disposal Site <br /> No:-of Units Equipment Storage/Cleaning Location0 <br /> Location(s) -. <br /> 6. 11 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 i <br /> Operator Name " -Where Certified <br /> Plant Location <br /> Plant Capacity -- No; Units Served <br /> 7..,❑'LAUNDRY For.July;l, -June 30, 19 <br /> SIZE"." ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> [:]-CRY CLEANING, Chemicals Used/Amount/Mo. <br /> x <br /> I <br /> 3 <br /> f F <br /> I hereby certify that I have prepared this application and that the work,lwill be done in'accordance with San Joaquin County <br /> i ordinances, state laws, anrules and reguI tions of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X j } <br /> FOR DEPARTMENT USE ONLY - <br /> r <br /> Fee Is Due: ❑ ANNUALLY . ❑ PER UNIT 11 PER SITE ❑ EACH ❑ January 1 &Re ed By-January 31 ❑ July 1 &Received By July 31 f <br /> BILLING RFMITkNCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> - DATE DATE REMITTED. - AMOUNT <br /> FEE q5�� <br /> LESS t x <br /> PRORATION x $; <br /> PLUS1, <br /> PENALTY - - - <br /> OTHER <br /> i OTHEFI - -' � _� �• <br /> Received by Dale Receipt No. Permit No, Ifs;uanclb Darle Mailed livered <br /> APPLICANT—RETURN ALL COPIES-0`O: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 001 E.HAZELTON AYE.;P.O.Box 2009 TOCKTON,CA 95201 <br />