Laserfiche WebLink
MjrIJI1Gt1UU113 YYllt DC rr VL ,Cu YY I1C11 JUUIl11 wl. r11JE1Clly VUIIIIJIVLtl..13V*. U 1711911 111c HIJV.Iuallvr <br /> APPLICATION <br /> (For Non-Translerable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> �. LIQUID WASTE <br /> Application i ,hereby made o arry on •u <br /> bus ss in the risdictionai area of the 5 Joaquin Local Health District <br /> r.6usiness Name (DBA) ' A ress y�+t, 7,g <br /> z Iwner Address <br /> 4 <br /> firm Partners, Addresses and Telephone Number <br /> E- Business Telephone No. Emergency Telephone No. <br /> contractor Licence No. Z� <br /> �ppiicants Name (Print) Title Date ! 5. <br /> i <br /> Please check Applicable Category (1-7) and Fill In the Required Informa on <br /> I <br /> El PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> for July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> rerial No. CAL. License No. CAL. Licznse Renewal No: <br /> apacity Gal.,Weights ii Measures No. <br /> -Equipment Parking Address <br /> t 2. ❑ PUMPER YARD <br /> i <br /> rl <br /> or July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> vNo. of Chemical Toilets Stored <br /> ' 11 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 ' + {l �C <br /> Job Address/Location G 1 d J <br /> OAddress <br /> tVPTIC TANK 11 CESSPOOL ACHI G FIELD El SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT ❑ TEMPORARY LZ NEW ❑ REPAIR ❑ OTHER <br /> ,5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 /> Where Certified <br /> #Operator Name <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> t SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ke;k ordinances, state laws, and rul and regulationnnI th Jo quin Local Health District, <br /> APPLICANT'S SIGNATURE X —� CC���' <br /> .IJ <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 /> 4 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT lb <br /> FFEE "VV <br /> j <br /> LESS <br /> PRORATION <br /> PLUS <br /> 1E 1 PENALTY <br /> OTHER <br /> OTHER <br /> ;;J <br /> Received by Date Receipt No. it - Iss ante a Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES, 1601 E.HAZELTON AVE.,P.Oj ST-0CTON,CA 95201 <br /> --� i .�t <br />