|
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign he Application.
<br /> APPLICATION
<br /> w (For Non-Transferable, Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT t
<br /> ` LIQUID WASTE
<br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District
<br /> OBusiness Name (DBA)I3,A. �ei�n�� 7vL��+Y.A � .. Address7. sf�X t4<����" 1�1I
<br /> a
<br /> 4 OwnerAddress
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> a Business Telephone No. �'4,q77 Emergency Telephone.No, _ _ y
<br /> Contractor Licence No.
<br /> L Applicants Name(Print) - a Title V 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,Jtiiy 1, - -.-June 30,.19 n Disposal Sites
<br /> Description(Make/Yr., Color)- .-.•- — _
<br /> .a,
<br /> Serial No. �� KCAL. License IVo. ' ' CAL. License Reneryal No.
<br /> .
<br /> Capacity Gal., Weights &'IJ�+?aasl�res�f>lo.
<br /> Equipment Parking Addresst
<br /> 2. ❑ PUMPER YARD
<br /> For July 1, June 30, 19
<br /> I n j
<br /> No. of Vehicles Stored `
<br /> No. of Chemical Toilets Stored
<br /> q
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S. or R.C.E. Nam — R.S.or'R.C.E. No...
<br /> Test L cation Test Date/Ti '
<br /> 4. SANITATION PERMIT 'k`• ',> la
<br /> Job Address/Locati n ' 4.
<br /> WOw er - !� Address }' --
<br /> EPTIC TANK, ❑ CESSPOOL EACHING.FIELD'4AKSEEPAGE PIT ❑ PACKAGE PLANT,.
<br /> Pi"PERMANENT TEMPORARY ❑ NE_WaREPAIR ❑ OTHER i
<br /> 5. ❑ CHEMICAL TOILETS For July 1,_,Jdne 30'419
<br /> Type Construction. € 1' -Disposal Site `"� ! An
<br /> -No, of Units I P 3 Equipment Storage/Cleaning Loeation(s-)
<br /> 6. 11PACKAGE TREATMEwNT PLANT 19 1 " J'une'b, 19 1 k
<br /> Operator Name —a. I € ' i ) Where Certified
<br /> I
<br /> Plant Location
<br /> .Plant Capacity f i } I No' Units Served
<br /> 7. .❑ LAUNDRY For July 1, -June 30, 19 �. %-A
<br /> SIZE: © Less Than 1,000 Sq. Ft:, „R ❑ °More Than 1,000q?fit: kr .
<br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo i ti
<br /> ,.
<br /> HoA180VL'R@TOrtiG6R^uflPias�$rt'S51gRaYUrQCETktiesth}lfollov&V t-if thalin tt p.rfr_.rmanceo`t!leworkfor;vhichL,snerrtiitisissuecf.ishall�lfltemola an+i -
<br /> in such manner as to been,-a subject t wnrl n tl ;at>�5^cation lar ",f C,a1 f<irr;l t j pe.
<br /> i ,{
<br /> Contractor'$ hiring or stltz-con?r3C'rr;; sig aaterec c4art,fie t1e f.kSu+rli:33: l "e_-Ny il'W'it the;`efl—iilanG Oft f:L 'K.f�t:';1lC.1 tN? CCmnit is issujd�l�spal`.,..., q�€
<br /> em;,loy persons sub;ect to wori.m.-f l;co2n,leR$ation lavzs cf Cali#ornla.ri9Y-
<br /> I t=•f4An t 4 iT r .�-•• f¢ t
<br /> hereby certify that I ha a prepared--.this applicatlort.and,-that w�rk'withbe done-in,accordance with Sall Joaqurn Couiityr +
<br /> ordinances, state laws, and regulat''s of'the S a in.L cal Health District.
<br /> APPLICANT'S SIGNATURE X
<br /> �� t
<br /> I
<br /> FOR DEPARTMENT USE'S LY Z. .- �•�iRt`" 4: +e. r i
<br /> Fee IS DUB: 1:1ANNUALLY PER"UNIT '� PER SITE EACH ❑ Januarytt+&'Recei By January 31 El July 1 &R calved?By,;fuly,-�I.
<br /> -- _s - - REMIT .,
<br /> BASE EXPLANATIDN
<br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED
<br /> DATEI !TATE . REMITTEDI } . AMOUNT
<br /> FEE. !
<br /> S
<br /> LESS
<br /> PRORATiON
<br /> PLUS '
<br /> PENALTY
<br />�.�.•-..�• -'"'-OTi-IER- �.....,.�--....,-,ice,. 4 - „,,,jr.. .� ,..�.," + ......,.e... ..,,.. -..,.-.3��,........�,�..e.,. .,.�,«..... -,-....,.,..�.
<br /> ? zs
<br />.�.....w..., ,.�OTHERa,i.,s..ersi.,+
<br /> Recewed,by Date Receipt No 'Permit No Is uance bei4e Mailed Delivered
<br /> ` APALICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALYH PERMIfISERVICES` '1601 E.HAZELTON AVE.,P.O"Box'2009 'STOCKTON=r:
<br />
|