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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transfeirable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati s hereby naqe to carry usiness in the jurisdictional area of th San Joaqui oc H th Dis rlct ff <br /> Business Name (DBA) �t�L� �F�� .Q T Address �� ArRr �,. <br /> z Owner Address <br /> J Firm Partners, Addresses and TI p ne Numbers <br /> aBusiness Telephone-No. Emergency Telephone No. <br /> Contractor Licence No. 43—1 <br /> Applicants Name (P Title, Date <br /> Please check Applicable Category(1-7)and Fill-in.the Required Information t > q <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) p�4 <br />` For July 1, June 30, 1gf s° `'. ,3.. ;fes Disposal Site _- <br /> f j <br /> k Description(Make/Yr., Color) <br /> Serial No, CAL. License <br /> /No:-N CAL. License Renewal No_ <br /> Capacity Gal., Weights &Measures o. <br /> Equipment Parking Address ; <br /> 2.;0-,PUMPER YARD <br /> For July,.1,. ; June 30, 19 _" <br /> 9 <br /> No. of Vehicles Stored ., 3 t L <br /> No. of+CheFnical,Toilets Stored y �. <br /> 3. ❑'PERCOLATION.,TEST <br /> R.S. or R.C.E. Name kJ R:S. or R.C.E. No. <br /> Test Location Test Dale7Time <br /> 4. ❑ SANITATIONI PERMIT02 <br /> Job Add Locati'pn- �►u `� � 1 -1 <br /> Owner _ } Address 1 a <br /> -...-_a .� •❑ PAC AGE PLANT <br /> .❑ySEf''TIC TANK P❑4' 3SPQOL`� --- .:LEA�.HJr4G FIELD] C2Y�EEPAG FITS <br /> PERM <br /> XNENT '- ❑ TEMPORARY - 12'FIEW 'T� AIRS ' ❑ OTHER <br /> 5. ;❑ OHE.MICAL TOILETS For July 1;1-June 30, 19 <br /> Type Construction �i: - - Disposal Site <br /> No. of Units' 1,Equipment Storage/Cleaning Location(s) 1' <br /> 6. ❑ PACKAGE TREATMENT-Rt. ANT For July 1, =June 30;19`, i <br /> Operator Name" -�#•-'-� � ( i ) ) '� - Where Certified <br /> Plant Location <br /> Plant Capacity } T t ( Nb.'Units Served �` • <br /> 7. ❑ LAUNDRY -For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than1j,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. i <br /> O <br /> 911 <br /> Thereby certify:that I:have'•p e r d this application and th r will be done in accordance with San Joaquin County <br /> ordinances, state laws, and s nd"regulations of <br /> J qu cal Health District. <br /> APPLICANT'S SIG <br /> ;.. FOR DEPARTMENT USE ONLY f <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 &Rece;ned'By July 31 <br /> i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE '$. AMOUNT DUE- CHECKED <br /> > DATE -DATE `REMITTED AMOUNT <br /> v <br /> FEE 5� �. t' <br /> LESS ,. - <br /> _PRORATION <br /> PLUS ' P �//} /� r f -4k- <br /> PENALTY -� 1' 't - - tiC_ "�� S Z <br /> OTHER . <br /> OTHER <br /> Received by Date Receipt No: Permit No. I Issua a le Mailed Delivered,�Y <br />} APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELT- .,P.O.Box 2009 STOCKTON,CA 95201 <br />