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Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSign TheAppllcatlon <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> r.. W1. ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is.. ereby mad carry on business in the jurisdictional area of the San Jo in Lo I HeaA Distri <br /> HBusiness Name (DBA) d Address <br /> Address <br /> a Owner <br /> u Firm Partners, Addresses and,T I phone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No, C <br /> LApplicants 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 /> Serial No. GAL. 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 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored 'Q <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test ocation Test Date/Time <br /> 4. SANITATION PERMIT <br /> Job Address/Loc tion tw/ <br /> Ow�� — Address �"f e- <br /> L� S�PTIG TANK ❑ CESSPOOLR LE ING FIELD EEPAGE PIT 13 PACKAGE PLA T <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIIR/��Q 0 OTHER 'J e--,v S y'l <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 u� les and regulations o the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X (/�'✓/ <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1.A Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS . <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 0,(r06_3 <br /> Received by Date Receipt No. Permit No. Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE P.O.Box 2009 STOC TO 261 <br />