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Applications Will Be Processed When Submitted Property Completed. Be Sure To Sign The Application.— R <br /> 0 APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH'PERMIT <br /> LIQUID WASTE " <br /> Application is reby made carry on usiness in the jurisdictional area of the San Joaquin ocal Health District <br /> Business Name (D . } Address �� �1 <br /> a Owner P " <br /> Address <br /> Firm Partners, Addresse nd Telephone Numbers <br /> Business Telephone No. Emergency Telephone-No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Tltle a Ef= _ Date_ Z <br /> Please check Applicable Category (1-7) and Fid in the Required Information <br /> 4 ? 3�e t; :ar. s '+ S <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) s <br /> For July T, " June 30, 19" Disposal Sites w <br /> Description(Make/Yr., Color) _ <br /> Serial No. k CAL. License No. CAL. License Renewal No. i <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 a <br /> .No. of Chemical Toilets Stored <br /> 3. EPERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. 1 7' <br /> Test L ation Test Date/Time �+ <br /> 4. SANITATION PERMIT <br /> Job Address/Location �, .� <br /> Owper Address 6 <br /> S�FF'TIC TANK ❑ CESSPOOL L`ACHING FIELD SEEPAGE PIT ❑ PACK GE PLANT <br /> [IMPERMANENT ❑ TEMPORARY lel NEW ❑ REPAIR ❑ OTHER ) <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site r it <br /> = a <br /> No. of UnitsEquipment Storage/Cleaning Location(s) # : } 4 q <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 f r <br /> Operator Name <br /> Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ 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 /> 1If <br /> � <br /> I hereby certify that 1 have p ared this applica o an that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r e nd gulations f he n Joagilin Local Health District: 1 '• <br /> APPLICANT'S SIGNATURE X <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY 'i <br /> ❑ PER UNIT PER SITE EACH Q January 1 &Received By January 31 ❑ July t 8 Received By July 31 <br /> BILLING REMITTANCE $ 1 '- REMIT <br /> ' BASE EXPLANATION DATE AMOUNT DUE CHECKED U r <br /> DATE REMITTED <br /> AMOUN i <br /> FEE <br /> LESS <br /> PRORATION , <br /> PLUS <br /> PENALTY <br /> OTHER a <br /> OTHER <br /> _� <br /> Received 6y Date Receipt INV. mio Issu c <br /> o. Per <br /> I e ate Mai d Delivered r <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMIT)SERVICE5 `1601 E.HAZEL AVE.,P.O. ox 2009 STpCKTON,CA 95201 - <br /> i n <br />