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Applications Will Be Processed When Submitted Properly Completed. HeSure Io sign tne..�t,r.p.,.. .• <br /> APPLICATION <br /> V (For Non-Transferable,Revocabie,and Suspendable) SEPTAGE ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> " LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> r <br /> Address Business Name (DB ) � s- <br /> v, Address <br /> aOwner Y lir y <br /> j Firm Partners, Addresses and Tel hone Numbers <br /> IL Business Telephone No. 3''`�� Emergency Telephone Na. <br /> 4 <br /> Contractor Licence No. Date <br /> Title <br /> L Applicants Name (Print) <br /> Please check Applicable Category-(1-7) and Fill in the Required Information La 'r , <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) w <br /> For"July 1, ' June 30, 19 = Disposal Sites <br /> Description(Make/Yr.,Color) ,CAL. License Renewal No. <br /> Serial No. CAL. License No. - <br /> Capacity at-rWeights-&-Measures-No. <br /> Equipme t Parking Address F' <br /> _.2. ❑ P 1 MPER YARD <br /> For July, June 30, 19 '•0 <br /> I No. of V hicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PIRCOLATION TEST R.S. or R.C.E.No. <br /> R.S.or R.C.E,Name -- <br /> Te t L }tion Test Date/Time A*OV� <br /> 4. SANITATION PERMt C <br /> Jo Add�ess/Location �'�`S - ---4 _r � aC <br /> ddress ; <br /> SEPT C TANK ❑ CESSPOOL -LEACHING FIELD0 SEpAGE PIT %?C <br /> ACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR THER <br /> 111, <br /> ❑ i MICAL TOILETS For July 1, -June 34, 19 �^+ 11 3-5 � <br /> 5. CNE 1` -- -' <br /> Type Construction y DisposallSite j. <br /> No. of'Units Equipment Storag eanirtig.Location(s) <br /> -ni C <br /> 6. ❑ PACKAGE TREATMENT PLANT t For July 1, -JuneO <br /> Where Certified <br /> k Operator Name <br /> Plant Loltation <br /> Plant Capacity No. Units Served <br /> 4 7. ❑i UNDRY For July 1,-June 30. 19 . <br /> P SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than Sq. Ft. , <br /> ❑ DRY ILEANING, Chemicals Used/Amount/Mo. I--- <br /> 1stereerliex'nsedegent'ssignatrirec3rt}fiarStailowi:{a:AZerfiify`ttiatlnlhe eriormanceottheworkforvrhicht permifisissued,ishai€sx. t mployan Lperson" <br /> �k1 Ilrttla4lner sCtv6ecome subieci tt,liorkpnan'G ciripensaticn Ows of Californl� <br /> I. �swa llibiaJ er si:b.colltractitlg ; <br />