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Applications WiN fie Pi ceased When Submitted Properly Completed. <br /> a APPLICATION , <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> s her y m rry o sine s i jurisdictional area of the <br /> Application i5art,d6�9J�in L I Health District <br /> AddressCJ r <br /> Business N (DC.. ) Addr ss• 6l <br /> a OwnerS'.�.�'1� <br /> c+c%L <br /> Firm Partners, Addresses and le- Numbers Emergency Telephone No. <br /> I <br /> Business Telephone No. �7tel <br /> I <br /> Contractor Licence No. Title Qe0 [ Date <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7)anlI in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) i <br /> For July 1, June 30, 19 1 Disposal Sites ' <br /> Description(Make/Yr.,Color) <br /> CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> IE For July 1, June 30, 19 <br /> t No. of Vehicles Stored <br /> E No. of Chemical Toilets Stored <br /> 4 3, 11 PERCOLATION TEST R.S. or R.C.E. No. <br /> k R.S. or R.C.E. Name Test Date/Time <br /> I <br /> Test Location <br /> 4. b?SANITATION PERMIT <br /> Job Address ocatio Address f <br /> Owner M��LE`ACHI�NO�FIELD ❑ SEEPAGE PI ❑ PACKAGE PLANT❑ SEPTIC TANK ❑ SSPOOL ��EPA1R 13—eTHER <br /> ❑ PERMANENT ❑ TEMPORARY C-1NEW (>� <br /> 5, ❑ CHEMICAL TOILETS For July 1, -June 30, 1Disposal Site <br /> Type Construction 0. <br /> F Equipment Storage/Clea ing Location(s) <br /> ! No. of Units i. <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 1 T Where Certified <br /> Operator Name <br /> Plant Location 1 1 No. Units Served <br /> Plant Capacity <br /> k 7. ❑ LAUNDRY For July 1, -June 301.19 <br /> k SIZE: 13 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq!Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/MO. <br /> the work-will be done in accordance with San Joaquin my <br /> j I hereby certify that 1 have prepared this ap a'on nd that 1 <br /> ordinances, state laws, an and regula San Joaquin Local Health District. <br /> 1 <br /> APPLICANT'S SIGNATURE �� 1 <br /> l{ ` <br /> k <br /> FOR <br /> [DEPARTMENT USE ONLY L <br /> F Fee Is Due: [1ANNUALLY ❑ PER UNIT , 13 PER SITE i ❑ EACH ❑ January 1 &Rec 'ved anuary 31 ❑ July 1 &Received EMITcly 3t <br /> BILLING REMITTANCE AMOUNT DUE CHECKED <br /> F BASE EXPLANATION DATE DATE R TIED AMOUNT <br /> i - 1 <br /> FEE }f <br /> LESS { <br /> r PRORATION <br /> PLUS <br /> PENALTY <br /> I OTHER <br /> sal <br /> OTHER ' <br /> Receipt No. Permit Nv. <br /> l suanc Date Mailed Delivered <br /> Received by Date t� 1501 E.HA2ELTON AVE.,P.O.Box 21109 5TUCKTON;CA 95201 <br /> I APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICE _ n <br />