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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> APPLICATION / <br /> (For Non-Translerable, Revocable, and Suspendable) SEPTAGE y <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE A <br /> Appl icati hereby ma e4o carry on iness in the jurisdictional area of the San Joaqui n Local Ith District <br /> ,F Business Name (DBA) • Address <br /> z Owner Address <br /> a <br /> J Firm Partners, Addresses and TelOhl <br /> ne Num ers <br /> aBusiness Telephone No. -._ Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) <br /> Title 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 /> CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. r <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. <br /> Test Date/Time <br /> Test Location <br /> 4. ❑ SANITATION PERMIT r ) <br /> I Job Addr ocation <br /> Owner Address O vE <br /> I' <br /> 11 SEPTIC TANK ❑ CESSPOOL SCE CHING FIELD 11 SEEPAGE PIT PACKAGE PLANT'`A, <br /> 1:1 PERMANENT 11 TEMPORARY <br /> l�"RE�! 1�'RFiSAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 "6 <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 /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity No, Units Served R- <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 /> I hereby certify that l have p � red this application an a ork will be done in accordance with San Joaquin County <br /> ordinances, state laws, and. s and re e n cal Health District. <br /> APPLICANT'S <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMI. RASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE { <br /> LESS <br /> PRORATION gyp, <br /> PLUS ®4ir <br /> PENALTY j <br /> OTHER <br /> t <br /> OTHER <br /> a `2 <br /> Received by Date Receipt—N.. Permit o. Issuan a Date Mailed D were <br /> _ 1$01 E.HAZELTON AVE.,P.O.Box2009STOCK N,CA 95 <br /> ' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES <br />