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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 /> r ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appl ication is hereby made to carry on business in the jurisdictional-area of the San Joaquin Local Health District <br /> N Business Name (DBA) Address <br /> z Owner IfIzeAddress <br /> e <br /> uFirm Partners, Addresses a�Telephone Numbers 9/ - <br /> a Lj' ., Emergency Telephone No. <br /> a Business Telephone No. _ No: <br /> Contractor Licence No. <br /> Applicants Name (Print} Q Title,d Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information i. 6v <br /> 1. ElPUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 4 Disposal Sites - — <br /> Description(Make/Yr., Color) I <br /> l No. I CAL. License No. - CAL. License Renewal No. <br /> Serial CapacityNo al�'VSff-t�fit-ts&=MtirasarerN . ._....._...---, <br /> r i ti <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD .: t <br /> For July1, June 30, 19' "t <br /> No. of Vlhicles Stored <br /> No. of Chemical Toilets Stored -y <br /> 3. ❑ PiRCOLATION TEST <br /> r R.S. or R.C.E.No. }' <br /> R.S. or R;C.E. Name <br /> Test Location Test Date/Time } I <br /> 4. ❑ SANITATION PERMITS <br /> Job Address/Location T 5 'll!�! <br /> r_�..• a <br /> }Ovy6er Address T$y:: I <br /> Jn SEPTIC TANK ❑ CESS 00' ❑ LEACHING F.ELD ❑' EEP14A E PIT ❑ PACKAGELf LANT <br /> ❑ PERMANENT ❑ TEMP ,AF�Y� ❑ NEW J" REPAIR 1:1 OTHER ..� <br /> °�. [ <br /> 5. I] CHEMICAL TOILETS ForJ5y June 30, 19 <br /> Type Q'4struction Disposal.Site <br /> E` ui ment Stora a/Cleanin Location s) C <br /> No. of`Units q P g g ( <br /> T , <br /> 6. ❑ P CKAGE TREATMENT PLANT o July 1,-June 30, 19 `. <br /> Operat%Name -: Where Certified t <br /> Plant Location , <br /> *1 f �No. Units Served <br /> Plant Capacity '. <br /> 7. ❑'eAUNDRY For July 1, -June 30, 19 � r <br /> SIZE:—A0 Less Than 1,000 Sq. Ft., C1More Than 1;;0j00_Sq.Ft. . <br /> ❑ DRY,CLEANING,Chemicals Used/Amount/Mo. r <br /> f� tlrtic'a�sa4aeti*t'��ign�gusrertiti sTleia4Fowirto:"t erti' a� tiin hh4.4dor irtceefthework fprkAi ch this pt if ISlssuad��II��'al rip � /anyp�'S� <br /> i111S911s r as to Rcx,Gl�ta snsjecS tuv�arklrra r: c9maensati 1r;lay's C s!;Eortra"•w�4t / + rFf <br /> �8' tlirfng dr sub rtat�Traeti:g sig tat �e csr1F57c it14 I:owi,13: "I Certify tl inthe perlarma 1c zf the v;ork r rihiClt this hermit is IS°v'r .I shalt <br /> ttpltnypt[t�n11s sz}hleCt to ir9rKrtali s o9mptnse la,�.ta1v t.Califori ia. <br /> I hereby certify that I have preparedst411s app�lcation and that the ork will be done in accord a ce with San Joaquin County �S <br /> ordinances, state laws, and rules and regulations$t the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE.X <br /> FOR DEPARTMENT USE ONLY- <br /> Fee Is Due: 13 ANNUALLY PER UNIT PER SITE ❑ 'EACH ❑ January 1 &Received By January 31 ❑ Juiy 1 11 Received By July;31 <br /> REMIT <br />* BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> I DATE DATE REMITTED. -- -AMOUNT <br /> s R <br /> FEE,'— { <br /> w LES <br /> PRORATION _ CSL <br /> PLUS \/- <br /> PENALTY' <br /> OTHER <br /> OTHER <br /> Received by Datek Receipt No. Permit No. Issuance to Maned Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL REALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O-Box 2099 STOCKTON,CA 95201 <br /> ' 1 <br />