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Applications Will Be Processed When Submitted Properly Completed. B <br /> APPLICATION <br /> = J_. (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTALHEALTH PERMIT <br /> f <br /> LIQUID WASTE <br /> � ppiicati is re made Xo c rryonsiness in the'urisdictional area oftanaquin Lo He h� j, trict <br /> Addrejj <br /> s <br /> mBusiness Name (DBA) <br /> z Owner .. Address <br /> a <br /> Firm Partners, Addresses and Tele, Nl�rr�bers Emergency Telephone No. <br /> a- Business Telephone No. t7(�y b <br /> a Q <br /> 1 Contractor Licence No. Date <br /> LApplicants Name (Print) Title <br /> i 7 and Fill In the Required Information } <br /> Please check Applicable Category ( - ) C <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l} <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 /> j 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 <br /> No. of Chemical Toilets Stored } <br /> 3. ❑ PERCOLATION TEST R.S. or R.G.E. No. <br /> R.S. or R.C.E. Name <br /> Test cation } Test Date/Time. <br /> 4. g;:; <br /> MIT t <br /> i S <br /> Job Ad <br /> E O ner Address w <br /> FSE CESSPOOL+ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> I. PERMANENT 13 TEMPORARY <br /> �NEW ' REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19" <br /> Type Construction Disposal Site <br /> Na. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 < <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> r Plant Capacity <br /> E 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> I SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this appli tion and that the work will be done in accordance with San Joaquin County <br /> $ ordinances, state laws,W rules and egulat' ns the Aaquin Local Health District. <br /> APPLICANT'S SIGNATURE X i <br /> r 1 <br /> FOR DEPARTMENT USE ONLY <br /> PER UNIT ❑ PER SITE ❑ EACH ❑ January 1,&Received By January 31 ❑ July 1 &Received By Juty 31 <br /> Fee Is Due: 0 ANNUALLY ❑ -REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - , BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> SFEE ' <br /> e <br /> LESS i Vic' <br /> PRORATION <br /> PLUS F <br /> PENALTY <br /> t OTHER <br /> OTHER ko <br /> Date Receipt No ermlt No.-- Issu nee Date M led Deli red <br /> I Received by y <br /> APPLICANT—RETURN ALL COPIES ENVIRONMENTAL HEALTH PERMITISERYICES 1601 E.HA2ELTON AVE., :2009 STOCKTON,CA 9520 -- <br />