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letea. ne <br /> Applications Will Be Processed When Submitted Properly omp <br /> APPLICATION <br /> r` (For Non.Transferable;Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH_PERMIT <br /> LIQUID WASTE + <br /> 1 <br /> Application is hereby made to carry on busine in the'ur'sdictional area of the San��uin Loc 1 Hea District <br /> Address <br /> UF Business Name (DBA) `J Address k <br /> a Owner <br /> Firm Partners, Addresses and elephone Numbers- Emergency Telephone No. k <br /> aBusiness Telephone No. r <br /> Contractor Licence No -4 Trtle ate <br /> L Applicant"s Name (Print} _ �x <br /> 1 T and Fill in the Required Information, ,- C; fi �..... <br /> Please check Applicable Category ( - ) <br /> f, ❑.PUMPER VEHICLE PERMITREGISTRATION (FOR EACH VEHICLE) <br /> i• Disposal Sites <br /> ,.-,:x ForrJUly 1,+ June 30;,19 p. <br /> Description(MakeNt., Color) CAL. License Na. r CAL, License Renewal No.!' <br /> Serial No. -- <br /> CapacityGal.,`Weights &-Measures-No: <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD , <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ---.-- ---- <br /> No. of ChemicallTToilets Stored ., ; i <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E.No. <br /> R.S.or R.C.E. Name Test Dale/Time <br /> Test-Location t ,- <br /> 4. ❑ SANITATION PERMIT O,` _ t <br /> f t. 13 -+ i <br /> Job Addres Location Addres . <br /> $. Qwrser ^ ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD- SEEPAGE PIT ❑ QTHER t <br /> ❑ PERMANENTS <br /> ❑ TEMPORARY ❑ NEW E AIR A <br /> 5. ❑ CHEMICAL(TOILETS For July 1,-June 30, 19 <br /> Disposal Site �`•��_ „p, � ¢°—�- <br /> 5 Type Construction}} 10 c`` •�`-rt,, <br /> No.of-Units i Equipment Storage/Cleaning.oation(s) <br /> }� <br /> g.4 ❑ PACKAGE�REATMENT PLANT For July 1, -June 3D, 1 ere Certified <br /> Operator-Name _ <br /> Pliant Location j�o­U7-'— <br /> N�Units Served - 4 <br /> Plant Capadity t <br /> T. 11 LAUNDRY `For July 1,-June 30;.19 <br /> � '- .� <br /> ` ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ftp- <br /> at <br /> S1ZE: <br /> ❑,DRY CLEANING, Chemicals Used/Amount/Mo~ tC <br /> Flo eo•sne'aPiacansedAgent'ssignaturecedifiasthefotEnvring:�;�,t,P,tti#y thatirthepsr#crmancenithe.workforxhichtltispermitisissuctl,Ishalfnotemployartyperson <br /> rn such marn—i a�to become Subject to worldmai S compensation laws of a3ifcr io." � <br /> "�-+cGritractor's hi rtg r sub-contracting sig';Ziiil a Certifies -Ke {�ttuwislfl: �1 certify that in the performance nl the work for ti*t;ich this permit is issued,I shall €'y <br /> er;,ploy persons sig - ct to workmaii sc ompertsaticii laws of 04 <br /> # <br /> ° <br /> - ll d <br /> done in <br /> r <br /> hereby certify t ave prepare this apPolns'f he San Joahuin LocailHe. Ith District. with San Joaquin County <br /> t ordinances, s laws,.a les an eg � <br /> APPLICANT'S SIGNFIT REX <br /> E- t FOR DEPARTMENT USE ONLY <br /> j 3 r ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 f <br /> ❑APER UNIT ❑ PER SITE . ❑ EACH REMIT t <br /> r <br /> Feels Due: ❑ ANNUALLY-� t_ ` I <br /> r . BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE r DATE REMITTED - AMOUNT y ; <br /> F <br /> °Q 5 <br /> FEE . ..'r;I <br /> j' <br /> LESS <br /> PRORATION f # <br /> PLUS <br /> F <br /> PENALTY <br /> �•. it I <br /> OTHER <br /> t .:,w..«r.�..Y•�+ .ves rte- aF_ - V, - ; <br /> OTHER � - <br /> r <br /> 1./ � .. Issuance Date ( Mei4ed <br /> { Receipt No. pe��nit No <br /> t Received by m_...... ate � 1 ;''1501-E:HAZ TON`AVE.,p.D.Box 21108 STOGyKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES-TO: ENVIRONMENTAL HEALTH PERMITlSERYICES ��, �r, y <br />