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Completed.tie sure I o.71gt1 1 tiK MtJFI,ww,vr•. <br /> Applications Will Be Processed When Submitted <br /> APPLICATIONP <br /> (For Non-Transterable,Revocable,and•Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> h LIQUID WASTE <br /> _ Applicat�ion is phereb ade to carry on b mess in the Lr' ictionaAaddressof tn ,� u� o dal H alth Distri t. <br /> Business Name (DBA),3.hsl Address <br /> i Owner <br /> u Firm Partners, Addresses and Telephone Numbers ��: Emergency Telephone No. <br /> 04, Business Telephone No. t <br /> Contractor Licence No. _ Title — Date <br /> LApplicants Name (Print) <br /> Please check Applicable Category(1-7)and Fill in the Required ntormstion <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) W <br /> Disposal Sites <br /> For July 1, June'30, 19 — II <br /> Description(Make Color) !r CAL.License Renewal NO, <br /> CAL. License No- <br /> Serial No. No. <br /> Capacity - - ti.1 <br /> 'Gal.,Weights&Measures � � , <br /> +`l._. <br /> .. t i el-l4 <br /> Equipment Parking Add_ressw ,- <br /> Z. ❑ PUMPER YARD yr <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TESTOr�R.C.E.No. <br /> R.S.or R.C.E.Name �- Test DatelTime <br /> � ' f � <br /> 4 <br /> Test Location i y / .r <br /> A. SANITATION PERMIT <br /> Job Address/Location Address f <br /> Owner ❑-PACKAGE PLANT�„� ! <br /> I <br /> ❑ SEPTIC TANK ❑ CESSPOOL 'g �LEACHWG.FIE'L SEEPAGE PRT OTHER ] <br /> PERMANENT ❑ TEMPORARY ❑ _NEW REPAIR # �, J► „� �. <br /> ❑ CHEMICAL TOILETS For July 1, w June 30, 19 <br /> Disposal Site <br /> ype Construction. ` ? <br /> Equipment Storage/Cleaning Location(s)�1 f <br /> No.of Units " J �' ''" �• <br /> ❑-PACKAGE TREATMENT PLANT For July,T;-June 3 �9 - <br /> 8. _ - f .r Where Ct#rtified <br /> Operator Name <br /> t \y <br /> Plant Location %) ' <br /> NofUnit's.Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July t" June 30. 19_ � `� .� 4 J e <br /> SIZE: ❑ Less Than 1,000'$q. Ft., <br /> ❑ More Therl"I'O 00zqNPt. <br /> r ❑ DRY CLEANING.Chemicals�Jsed/Amount/V-5." <br /> b <br /> I hereby certify ttta I^ha1+e prepared xhiU`appjic 9t a San Joaquin Local lHeall gth District. <br /> dohe in accord <br /> with San Joaquin County <br /> ordinances,state lawn and rules antl._ � !f ; <br /> tl <br /> F . <br /> f APPLICANT'S SIGNATURE X011 <br /> f <br /> FOR DEPARTMENT USE ONLY 7�/ <br /> 6 Jul3.1 <br /> Fee($Due' 13 ANNUALLY PER UNIT ❑ PER SITE 13 EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Recew REMIT 'y <br /> } BILLING REMITTANCE $ AMOUNT DUE CH@CKED <br /> SASE EXPLANATION DATE DAZE j3EM1TT� —^«�- AMdUNT <br /> .., <br /> FEE r <br /> LESS �. Y <br /> PRORATION g <br /> PLUS 5 <br /> PENALTY <br /> 'pr <br /> OTHER r fi Z <br /> D OTHER - y�, ` , -+. t { F C.J•- <br /> i{ " u Date mailed t Delivered " <br /> t Nai t Permit No.. <br /> ec <br /> Reived by Date Receipt i% 1g01 IE HAZELTON AVE.,P.O.Box 2DO9 STOCKTON,CA 96201 <br /> APPLICANT—RETURN ALL COPIES TO- ENVIRONMENTAL HEALTH PERMITISERVIC)ES_ <br /> u .. a war• <br />