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, -7e4; Applications Will Be Processed When Submitted Properly Completea. lie bure I o sign r ne Application. <br /> . APPLICATION <br /> ur Non-Transferable, Revocable,and Suspendalr�- j <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE 1 <br /> Applicata Is/h eb ade�to c�a on u ass in the' risdictional area of th andjpquinLocqjW,0ea strict <br /> AddressIq <br /> Business Name (DBA) i_./?u— l � •-�4 ! '_ � <br /> z Owner Address <br /> a <br /> 2.Firm Partners, Addresses and Te hone Numbers <br /> a. Business Telephone No. � a Emergency Telephone N <br /> a <br /> Contractor Licence No. — �� <br /> L Applicants Name (Print) Ito Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal Na <br /> Capacity Gal', Weights &Measures No. � <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> I <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST v <br /> R.S.or R.C.E. Name R.S.or R.C.E. No. G. <br /> Test ocation Test Date/Time <br /> 4, SANITATION PER T _Q <br /> Job Addr s/Loca ' n50 W <br /> JIV- G(' <br /> Owner Address <br /> %SEPTICTAd/ ❑ CES POOL KLEACHING FIELD ❑ SEEPAGE PIT PACKAGE PLAN <br /> PERMANENT ❑ TEMPORARY NEW 11 REPAIR ❑ OTHER <br /> 5. 11 CHEMICAL TOILETS For July 1, 'June 30, 19 C <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. 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: IT Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. # <br /> ki <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County I <br /> ordinances, state laws, and ales and reg ations _ San J a in Local Health District. <br /> r <br /> APPLICANT'S SIGNATURE X <br /> Z7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee l's Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REM17 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUSI <br /> PENALTY <br /> �+ <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Iss nce Date a Delivered <br /> STOCKTON,CA s5 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P. x 2009 <br />