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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transterable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat' i hereb'yacre to carry business in the jurisdictional area oft oaqui ocal- Dista <br /> y Business Name (DBA)� ri�`�) AG <br /> r Address Q <br /> i Owner .. Address <br /> Firm Partners, Addresses aOho Num ers <br /> CL Business Telephone No. � Emergency Telephone No. <br /> a - <br /> -J Contractor Licence No. - - <br /> L Applicants -Title Date <br /> Please check Applicabl Categoryo-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. CAL. 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 f <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored r <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. ❑ SANITATION PERMIT <br /> Job Addre Ca 'on <br /> Owner Address <br /> ❑ SEPTIC TAAK ❑ CESSPOOL ULEACHING FIELD MPAIR <br /> AGE PIT ❑ PACKAGE ANTElPERMANENT 13TEMPORARY ❑ NEW ❑ OTHER 4 ' <br /> s. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 - ? <br /> t <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- t <br /> Plant Location <br /> Plant Capacity I; No Units Served C <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq" Ft., ❑ More Than 1,000 Sq.[Ft.� .� k <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. ` t' <br /> I hereby certify that I have ep d this application t thew k'will be done iri acyordance with San Joaquin County <br /> ordinances, state laws, and U. <br /> and re ulati Joaqu' coal He Strict. <br /> APPLICANT'S SIGNAT <br /> 1!` <br /> F61514dPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT C3 PER SITE ❑ EACH ❑ January 1 8 Received!By January 31. I❑ July 1 &Received By July 31 <br /> BILLING REM CI- $ n <br /> REMIT <br /> BASE EXPLANATION �AMDUNT DUE CHECKED <br /> DATE D AMOUNT <br /> � 5w f <br /> FEELA2� r 01 <br /> LESS <br /> PRORATION 11101S f f <br /> PLUS <br /> PENALTY <br /> OTHER <br /> -OTHER <br /> _ <br /> Received by Date Receipt No. Permit No. ; �,ti. i Issuance Da'.f:.?ti,_�blailed ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVS;PO: r2009 STOCKTON,CA 95201 . <br />