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' Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> a•''+' (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ' ENVIRONMENTAL HEALTH PERMIT <br /> u LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the Sen Joaquin Local Health,District . <br /> ' lame (DBA) <br /> r Atlifress <br /> 14A4Lrex TZ244f Address X23 id EL i 1 TT L i GA. 3 <br /> :rs, Addresses and Telephone Numbers <br /> elephone No : eo-:-•:, r Emergency Telephone No. <br /> ' Licence No. <br /> Name (Print) Title , Date <br /> ck Applicable Category(1-7)and Fill-in the Required InMnna4on. <br /> 1. <br /> APER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) _ <br /> June 30, 19 - Disposal Sites ' <br /> 1(Make/Yc,Color) . <br /> CAL. License No. _ CAL License Renewal No. <br /> Gal.,Weights&Measures No. <br /> Parking Address _ <br /> APER YARD <br /> ' June 30. 19 - . <br /> icles Stored <br /> lmical Toilets Stored <br /> ' ICOLATIO-N�TvE$T <br /> ..E. Namey�OAC . R.S.or R.C.E.No. <br /> ion .,�/1 <br /> 74 d LR --j 2 dgt. , te:/Time <br /> J17ATION PERMIT ��vr0 �v,^h fJ : 4 �-7 <br /> ' sa/Location a'am - <br /> TANK ❑ CESSPOOL ❑ LEACHING'FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ' eNENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> EMICAL TOILETS For July 1,-June 30; 19 <br /> druction Disposal Site <br /> b Equipment Storage/Cleaning Locatien(s) <br /> ' SKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Mme Where Certified <br /> tion <br /> ' city <br /> ". a- No. Units Served <br /> JNDRY �Fbr July 1, -June 30, 19 <br /> 7 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> .EANING,Chemicals Used/Amount/Mo. <br /> ne owderorllcansed aesnt's sElRalaredY.dliosiha(viaowirg:"!certlh that!nthe performance of lhowork lorwhichth!s permit isissued.lshati IatempPoy <br /> al manner as to bel so to wmkm:.r.'s compensation faces st Ca!to:nia." <br /> wactor's hirllls or sub-curtracdru algal oardnes Lha following: "I certify that in the performance of the work for which this permit is issued, <br /> ploy persons subiod to workmaae censpe053tlbn Iflwa of Cente lla:• <br /> ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rules and regulations of the San Joaquin Local Health District. �j <br /> IT'S SIGNATURE <br /> �` <br /> FOR DEPARTMENT USE ONLY <br /> ' Is Dire: ❑ ANNUALLY ❑PER UNIT ffy�e <br /> ❑ PERBETE ❑ EACH ❑ January 1 a Paceived By January 31 ❑ July 1 a Received By JI <br /> BILLING REMITTANCE S REMIT <br /> DATE DATE REMITTED AMOUNTDUE CHECKEI <br /> AMOUNT <br /> iATION <br /> ILTY <br /> AER pNo. Permi!N Issuance Dale Mailed Delivered <br /> 'FUCANT—RETURN ALL COPIES TO:` ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O,ll 2001 STOCKTON,CA 95: <br />