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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reby madeto rry on business in the jur' dictional area of the San Joaquin Local Health Di rict <br /> OF Business Name A) Q. c - Address PeE <br /> z Owner Address ��•^� <br /> a <br /> J Firm Partners, Addresses and Telephone Numbe <br /> a. Business Telephone No. 3L�' �S`l -� Emergency Telephone No. <br /> Contractor Licence No, 2 <br /> Applicants Name(Print) Title Date <br /> Please check Applicable Category(1-7) and Fill in the Require 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 3.0, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATIOWTEST <br /> R.S. or R C.E. Name R.S. or R.C.E.No, <br /> Test Test Date/Time " <br /> 4. SANITATION PERMIT �c <br /> Job Address/Location <br /> Ow er Address '~ ' <br /> ,s PTIC TANK ❑ CESSPOOL LEACHING FIELD R_ Tw_O—WAGKAGE PLANT-- G <br /> L7 PERMANENT 13 TEMPORARY 11 NEW REPAIR ❑ OTHER V( <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Locativn(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 I rb$ <br /> Operator Name Where Certified— - =2 <br /> Plant Location I t <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. "�Y► . .;± - <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 hereby certify that I have prepared this application and that the work will be done in fl@rdance with San Joaquin County <br /> ordinances, state laws, and rules and ulations of the San Joaquin Local Health Distric . <br /> APPLICANT'S SIGNATURE X <br /> IN <br /> FOR DEPARTMENT Uyenuary <br /> Y <br /> Fee Is Due: 13 ANNUALLY [I PER UNIT ❑ PER SITE ❑ EACH &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING TANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE E <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. ' 1 uance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />