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Applications Will Be Processed When Submitted Properly Completed. Be SureToSignTheAppllcauon. <br /> APPLICATION <br /> (For Non-Transterable, Revocable, and Suspendable) SEPTAGE Q <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Apphcatio is hereby e t arry usiness in the jurisdictional area of the Sa oaqui oval H alth Distric <br /> Business Nam A) Address <br /> i Owner fP G Address <br /> a <br /> J Firm Partners, Addresses and Teleph e umbers 00 . <br /> a. BusinessTelephone No. -3 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) <br /> P�L Tit1e �W.� Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> 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 <br /> R.S.or R.C.E. Name R.S. or R.C.E. No. Q. <br /> Test Location Test Date/Time '- <br /> 4. ❑ SANITATION PERMIT <br /> Job Address ocation <br /> Owner Address Ob 4 <br /> 3-SEPTIC TANK ❑ CESSPOOL ❑ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ZI-NEW ❑ REPAIR B-OTHER ST"-"PO <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r <br /> I hereby certify that I have prep this appli on and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and r d regulatio h an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X , <br /> 117 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ Jan ary 1 &Re ved By January 31 ❑ July i &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTAN $ AMOUNT DUE CHECKED <br /> DATE DAT REMITTED AMOUNT <br /> J <br /> 1 FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> S <br /> Received by Date ReceipKN Permit Nv. Issuance Date Mailed De ver <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMEMIT/SERVICES - 1601 E.HAZELTON AVE 21109 f� ON,CA 9 201 - <br />