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. Applications Will Be Processed When Submitted Properly o 7 <br /> • -- APPLICATION 11 <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE i <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic ion is hereby mad rry on sines$"n a jurisdictional area of �njlqu ,Lo al Health ict <br /> Addre " <br /> yBusiness Name (DBA) Address <br /> i Owner L <br /> a <br /> R Firm Partners, Addresses and Telephone Numb rs Emergency Telephone No. # <br /> 0. Business Telephone No. _ y <br /> Q pate <br /> Contractor Licence No. Lim Title <br /> Applicants Name (Print) (� <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1, [3PUMPER;VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> CLE) . <br /> 19 Disposal Sites <br /> June 30, <br /> For July 1, ' <br /> Description(Make/Yr., Color) <br /> CAL. License No, _ CAL. Licensee Renewal No. <br /> Serial No. -- - •_ _ '- <br /> µ g. Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> •-For Suly'1� <br /> No. of Vehicles Stored Y <br /> No. of Chemical Toilets Stored <br /> 3, ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PE I s 0 i�E,IL�- <br /> ( Job Addr�} s/ ocai on �1 Address <br /> f Owner ` EACHING FIELD ❑ EE AGE PIT ❑ PACKAGE PLANT <br /> ►. ❑ SEPTIC TANK ❑ CESSPOOL 13 OTHER, <br /> ❑ PERMANENT' ❑ TEMPORARY C1 NEW REPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1;-June 30, 19 ! <br /> } v Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location($) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> Plant Location No. Units Served <br /> Plant Capacity <br /> 7. C3LAUNDRY, For July 1, -June 34 19 <br /> SIZE'. ❑ Less'Than 1,000 Sq. Ft., `❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Alkiount/Mo. <br /> k � <br /> .I.hereby certify at I h nd rules prepared d r this <br /> ulatpipinsatf n e San Joaquin Local will <br /> Heaeth Distr ct done in accordance with San Joaquin County <br /> 'ordinances, state 1a 19 <br /> j APPLICANT'S SIGNATURE '� <br /> _ h FOR DEPARTMENT USE ONLY <br /> ❑ PER SITE ❑ EACH ..❑ January 1 &Received By January 31 ❑ July-1 &ReceivedByJuly 31 <br /> MIT <br /> Fee is Due: Cl ANNUALLY- �� PER UNIT - - CHECKED <br /> KILLING REMITTANCE $ AMOUNT DUE <br /> _ BASE r EXPLANATIONDATE DATE REMITTED AMOUNT <br /> 1—� 0 <br /> FEE L <br /> I LESS - <br /> PRORATION <br /> PLUS I <br /> PENALTY z q i <br /> OTHER <br /> OTHER r <br /> L <br /> l suance Date Mailed Delivered <br /> Receip No. Permit No. <br /> Received by Date -16D1 E.HAZELTON AYE.,P.O.Box 2009 �STOCKTON,CA 95201 <br /> E: - ppve b RETURN Al-CCOPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES - - - - <br />