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nPIYIILOIIVHO TV nl Uc I ICII JUUIIU4ICV r VFVI Iy VVII1PAClCV. Iiv .,u IV IV-%j I I c' FF4 0. L <br />! <br /> APPLICATION <br /> Jr Non-Transferable; Revocable, and Suspendabl ,' SEPTAGF G <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicnon is hereby ma le to carry onusin s i he j 'sdictionaE area of thq.4$an Joaq n Local Health Dis r ct <br /> F rBusine ame (DB Address_��r7, -, t5cw <br /> I Owne Address <br /> Firm Partners, Addresses anted Tele hone �mbers <br /> i Business Telephone No. __���c7. %� <br /> a Y � ......— Emergency Telephone No. t�c <br /> Contractor Licence No. r <br />! Applicants Name (Print) Title R Date -� <br /> Please check Applicable egory (1-7) and Fill ' he Required Information <br /> 1: ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) c �i <br /> For July 1, June-30, 19 Disposal Sites l/� <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br />' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER-YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles.Stored <br /> No. of ChemicaE Toilets Stored <br /> 3. -❑ PEIRCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lo on Test Date/Time <br /> 4. V SANITATION PERMIT <br /> Job Address/ ocation <br /> Ow e Address <br /> SEPTIC TANK 11 CESSPOOL —r�, EACHING FIELD EEPAGE PIT 13 PACK <br /> GE PLANT finn'• <br /> 11 PERMANENT 0 TEMPORARY 0"N EW ❑ REPAIR ❑ OTHER �+ <br /> r 5. 11CHEMICAL TOILETS For July 1, -June 30, 19 0 <br /> I, 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 f <br /> Plant Location _ <br /> Plant Capacity No. Units Served <br /> 7. 1:1 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> r Hon;eownerorticettsedagant'ssignat+lrocArtetiesthe`olowing:"!c€rtifrth st!^t`1C*edormanceofthework forwhich tltispermit isissued,Ishall not employ any person <br /> In such manner as to become subjeex fo NI­,i'kn-tmr?S i;anip; lsaltu'la'IJS Cf Ca.li4r;i�n,'Contractor's hiring or Sub-contracting s n.oxarA Gj,r,;fdFs r,�c €pl owing; `1 certify That in the performance of the work fo:which this perrli€is issued,I shall <br /> employ persons subject to workmars's compensatio:l!aws of Cahto;nia." <br /> I hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules and reg ations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> �. FEETct <br /> n <br /> F LESS <br /> = PRORATION <br /> PLDs w <br /> PENALTY <br /> OTF[ER �I <br /> OTHER <br /> I r <br /> Received b i <br /> y Date' Rece pt No. Permit No. ssua a Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />