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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati �i �by ma e o caFry'on usiness in the jurisdictional area of the San Joaq i Local alth District // <br /> F Business Na a {DBA) C3 Address ? /S�" <br /> aOwner, l Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No, 4,1C Emergency Telephone No. <br /> -J Contractor Licence No. _ <br /> Applicants Name (Print) Title �rs� Date c x_ <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) /11 <br /> Serial No. CAL. License No. CAL. License Renewal No. J <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 /> 4. v4—d16ANITATION PERMIT <br /> Job Address/Location Z 5;0 <br /> Owner Address <br /> EDTIC TANK 1:1CESSPOOL EACHING FIELD 11SEEPAGE PIT ❑-PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY -i�JVEW ❑ REPAIR f ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 Q <br /> Type Construction Disposal Site a <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. i <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. r <br /> I hereby certify that I have ep d this a lication nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rul re a 'o of a San J uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> If Q <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &.Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE HATE REMITTED <br /> �+ AMOUNT <br /> FEE <br /> LESS <br /> PRORATION ' <br /> 1<2 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Issu ce DWiled Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTO VE.,P .Bax 2009 STOCKTON,CA 9$201 <br />