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Applications Will Be Processed When Submitted Properly Completed. tie sure tooiyrt roa <br /> APPLICATION { <br /> - (For Non-Transierable, Revocable, and-Suspendable) SEPTAGE11 <br /> r' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Ij LIQUIO WASTE t. <br /> Application is hereb ade to carry on b siness in the uri ictional area of th n Joaquin Local 1.H alth District. <br /> Business Name (DBA) r` 3 � Address <br /> a Owner Address <br /> 13 <br /> U Firm Partners, Addresses and Telephone Numbers <br /> a Business Telephone No. <br /> t % Emergency Telephone No. <br /> Contractor Licence No , <br /> a} Title _ "f <br /> L Applicants Name (Print) an <br /> Please check Applicable Category (1-7) and Fill in the Required)niormation i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites W <br /> IJ <br /> Description(Make/Yr., Color) , 111<1) <br /> Serial No. f CAL. License No. GAL. License Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> � - <br /> Equipment Parking Address, <br /> i 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 »,No. of Vehicles Stored - ti <br /> No. of Chemical Toilets Stored <br /> r 9 <br /> 3. E] PERCOLATION TEST •- <br /> 'R.S. or R.C.E. Name ) R-S.�or�R.C.E. No. <br /> w I! Test Date/Time' `r <br /> Test Location <br /> 4. =4SANITATION PERMIT <br /> Job Address/Location ` ` <br /> Owner . A). -�Atry Address fi <br /> 11 SEPTIC TANK ❑ CESSPOOL �� LEACHIN 3 FIELD ,SEEPAGE PIT F-1,PACKAGE PLANT <br /> IfRPERMANENT ❑ TEMPORARY C3 NEW WREPAIR © OTHER * :. <br /> 5. ❑ CHEMICAL TOILETS For July 1, June 30, 19 <br /> Type Construction t Disposal .Site " <br /> Equipment Stora Storage/Cl Location(s)e ; <br /> ` No. of Units '`"rg 9 <br /> 6. ❑-PACKAGE TREATMENT PLANT For Julyj,--June 30; 19,_. <br /> Where Certified <br /> Operator Name <br /> Plant Location \y <br /> s' <br /> li NCtrLJniis.Se�ed 'F` <br /> t Plant Capacity ;e <br /> 7. ❑ LAUNDRY For July 1-June 30,'19 <br /> A-` <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., 0 More Than ',0013 Sq:'Ft <br /> r <br /> DRY CLEANING, Chemicals Clsed/Amount/Mo. f. r..` <br /> 9q #_ r <br /> I hereby certify thatil'have prepared this'application and that the work will be done In accordance with San Joaquin Ceunty <br /> ordinances, state laws,and rules andegulations#t sari�oaquin Local Health District f <br /> APPLICANT'S SIGNATURE X ,�➢ ` xw <br /> FOR DEPARTMENT USE ONLY <br /> i !! <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE [],EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received y July 31 <br /> REMIT ' <br /> BILLING REMITTANCE $ AMOUNTqDUECHECKED <br /> BASE EXPLANATION }¢DASE r..r DAT,£ .�f3EMITIEDy __. —i a AMOUNT <br /> FEE <br /> LESS <br /> PRORATION - <br /> PLUS <br /> PENALTY :I <br /> OTHER f] <br /> S <br /> OTH <br /> ER <br /> Wsue <br /> EReceived by Date Receip[No. Mailed a Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICEs 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />