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$ Applicatlons Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> �I APPLICATION <br /> ` (For Non-Transferable; Revocable,and Suspendable) SEPTAGE _ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry o business in the jurisdictional area of the Sal�aquin Local Health District <br /> i rn Business Name (DBA)� �/r��� Address LL'�� 1< /47-4-,4 <br /> zOwner /,Py9_ Address <br /> I J Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. . I� y <br /> Applicants Name (Print) ? - Title - Date TK_ p— �r <br /> Please check Applicable Category�(1-7) and Fill In the Required Information <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 A Disposal Sites <br /> Description(Make/Yr.,Color) I f <br /> Serial No. CAL. License No. f CAL. License Renewal No. {( <br /> Capacity �� Gal., Weights & Measures No. i <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19�4 <br /> No. of Vehicles Stored iM <br /> No. of Chemical Toilets Stored It <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name I� R.S. or R.C.E. No. <br /> Test Location IM Test Date/Tine <br /> 4. ❑ SANITATION PERMIT I� i <br /> Job Ad ress/Location l _c f i t <br /> Ow r _ A dress <br /> SEPTIG_TANK CESSPOOL 'C, LLCHING FIELD ❑ SEEPAG� PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT �❑ TEMPORARY I-' I EW ❑ REPAIR ❑ OTHER <br /> 4. <br /> 5. ❑ CHEMICAL TOILETS_ For:`July 1, -Jun 19 d: <br /> Disposal Site <br /> Type Construction 4 .J6 `�'.'.- <br /> Y . <br /> No. of Units IM Equipriirf&Storage/'Ggleeani ng;Location(sj <br /> 6. 11PACKAGE TREATMENT PLANT For July 1, -June 30,°19—. O <br /> Operator Name i — Where Certified <br /> Plant Location <br /> Plant Capacity 7. `*° No. Units Seed <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/A, ount/Mo. <br /> I hereby certify t Fa r I;have preparea th'i's aiplication and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,!and rules and regula' ns a San oagLin Local Health District. <br /> APPLICANT'S SIGNATURE X r <br /> FO'i�DEPART IVT USE ONLY <br /> Fee IS Due: I� ANNUALLY_ ). ❑ PER UNIT ❑ PER SITE f ❑EACH# ❑ January 1 8 Received By January 31 ❑ July i &Received By July 31 <br /> I ' rv. REMIT <br /> { BILLING f REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> FEE (4�1�. a. <br /> LESS 1 <br /> PRORATION <br /> PLUS II 1 a I <br /> PENALTY I <br /> OTHER <br /> OTHER <br /> Received byDate' Receipt No. Perms No. I5 ante D to Mailed Delivered <br /> APPLICANT—RETURN ALL COP31ES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />