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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> T (For Non-Transferable, Revocable,and Suspendable) n <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE . <br /> Application is h by Made to cr on usines in the'uris icti nal area of the S Joaquin Local Health District •..� <br /> j y Business Name (DB dress� �� �V 7 <br /> ! z Owner ddress <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> I a Business Telephone No. Emergency Telephone No. <br /> dc <br /> Contractor Licence No. <br /> Applicants Name (Print) 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 /> 1 Serial No. CAL. License No. CAL. Lic�.-ise 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. <br /> Test Location Test Date/Time <br /> I 4. ❑ SANITATION PERMIT I <br /> Job Address/Lo ionAf <br /> Orw��r Address <br /> TIC TANK ❑ CESSPOOL �, L�CHING FIELD ❑ PACK E PLANT <br /> L1�PERMANENT ❑ TEMPORARY ix NEW ❑ RE AIR v ❑ OTHER <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 /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules regulatio of.4�vtAfjoaquin Local Health District. <br /> 0. <br /> APPLICANT'S SIGNATURE X <br /> DP FOR DEPARTMENT USE ONLY _ <br /> I Fee Is Due: 13 ANNUALLY ❑ PER UNIT lP PER SITE ❑ EACH ❑ January 1 &Received.By January 31 ❑ July 1 &Received By July 31 <br /> IF{ BILLING REMITTANCE $ REMIT AMOUNT OUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED <br /> AMOUNT <br /> F FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> { OTHER <br /> OTHER <br /> C) 7 � <br /> o t <br /> Received by Date w Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 20 STOCKTON4CA 1 I< <br /> T3. x. ����� �� !x �l' 7 cJ Til <br />