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^MM""•'•'"'a' •r... us . .v.-saacv n..c..VM4...14.SM' .Y�/c u� ...v...r..c.ev- uc vwc av v.y.. .nc r.p.p.ws...v... <br /> APPLICATION <br /> 1.or Non-Transferable,Revocable,and Suspendabt., - SEPTAGE '' <br /> ENVIRONMENTAL HEALTH PERMIT - <br /> LIQUID WASTE <br /> Application is hereby Wde to carry on bysin ss in the jurisdictional area of theaan Joa�uin'Local Health District <br /> O Business Name (DBA) ,J4, �' ++ Address � <br /> es. —{'�._ / 02 �.�z0I <br /> aOwner Address <br /> .Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No., y�� �a Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants (Print) i d Title <br /> Name Date <br /> Please check Applicable Category(1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) } <br /> Serial No. CAL. License N+?: <br /> _ __��_,'___ CAL.License eI No. - •- - <br /> .Capacity Gal.,Weights&Measures No. m <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, -June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored i <br /> 3. ❑ PERCOLATION.TEST <br /> R.S. or R.C.E. Name .or R. No. <br /> Test Location /Ti e <br /> 4. W SANITATION PERMIT <br /> Job Address/Location <br /> Owner ddress ' <br /> ,® SEPTIC TANK f CESSPOOL -LEAC NG IELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT " • <br /> 4 l�'� z <br /> PERMANENT' ❑:TEMPORARY ;.,NEW '❑ REiPAIR ;❑ OTHER = ,, <br /> 5_. ❑ CHEMICAL iOILETS For,.July 1, -June 30, 19 <br /> Type Construction r" Disposal-Sie <br /> No.of Units _ Equipment Storage/Cleaning Locahon(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1 June 30, 19: <br /> Operator Name w Where Certified <br /> Plant"Location <br /> Plate Capacity No tits Served <br /> w <br /> 7. ❑ LA`tJNDRY For-,July 1 June 30,,19 - 4, x 4 � <br /> SIZE: ❑ Less than 1,000 Sq.-Ft., J More ThaW1,000 Sq. Ft. a <br /> ❑ DRY GLEANING Cheri iicals UsedtAmount/Mo <br /> Hoiiliibwr+erorfiaensedagehtgsl¢natwncRr#+f~e#tlletoilawirx> Ira"Ylf�thatlhtha �rfc•rm�'eG 4fth�wArkt�rWhl tilt ;Atrmlti�l��»��hl�ha11 1�r,1 f �y��¢� <br /> in such=manner as to become subject to vrorkno�tlr:camf>ensaSimi latus off ii�rnl :' g <br /> Contractor`s ,hiring -or sub-contracting signature:csrtifMs to" 01OW4191 "1 Gerlify!#t !In the°peri@rfii�laC&@i lllc 1'1@Ti(iFf 4^�i11 11 title @ftllltl@ t pd,l Sidi <br /> n'scompensatron ia <br /> F�nQ1 y persons subject to waricmaws of California:' <br /> ,t fiereby certiW-that I have prepared this application and that the work will +be done in accordance with San Joaquin County <br /> ordinances, state laws, and r I end r <br /> SIGNATURE <br /> of the Sa oaq 'n Local Health District. <br /> APPLICANT'S SIGNATRE X <br /> _ I <br /> 0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS DUe ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE El EACH El January 1 &Received By January 31 July 1 &Received By July 31 <br /> REIT <br /> BILLING REMITTANCE $ <br /> BASE E7(PLANATION HATE AMOUNT DUE CHECKED <br /> r .._. ._.�... _. .;. . DATE ;.REMITTED w AMOUNT <br /> FEE /. <br /> ID <br /> LESS <br /> PRORATION ' <br /> PLUS >10111 f` <br /> PENALTY l� <br /> OTHER <br /> OTHER <br /> 531 l �- . <br /> Received byDate Receipt No. Permit No. I Issu nce D e led Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES1601 E.14AZELTON .,P.O.Box 200 N,CA 95201 <br /> i <br />