Laserfiche WebLink
tApplications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> ' (For Non-Transferable,Revocable,and Suspenciable) SEPTAGE <br /> Yom„ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ¢- LIQUID WASTE <br /> Application her y ma�deJnto carry on business in the Jurisdictional area of the sin J a j3 02VA Disi a 9� J <br /> Business Name (DBA) r .T2?I S ,Address..,/'' r , <br /> Owner__.. _ - Address .. _ <br /> j Firm Partners,Addresses and glephone�. Numbers <br /> Emergency Telephone No- <br /> Business Telephone No. lad _ ~ <br /> Contractor Licence No, <br /> Date <br /> Applicants Name (Print) Title . <br /> Please check Applicable Category (1-7):and,Fill In_the Required Inform IIOn.. i r,r. l,y,,- <br /> ' 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, -June-30, 19 - - Disposal Sites <br /> Description(Make/Yr.,Color) CAL. Llcense.Rereewal No <br /> Serial No. � CAL. License No., <br /> tCapacity Gel.,Weighis &Measures No. - <br /> Equipment Parking Address - - <br /> 2. ❑ PUMPER YARD - <br /> For July 1,% June 30. 19 <br /> No.of Vehicles Stored r ... <br /> No.of Chemical Toilets Stored <br /> ' 3. ❑ PERCOLATION TEST - R.S.or R.C,E.No. <br /> R.S. or R.C.E. Name <br /> Test Date/Ti <br /> Test Location <br /> rne <br /> Q. q SANITATION PERMIT <br /> ' Job Address/Location zg 6o/ �q�,...2 <br /> Owner V sI Cr� Ot2e d Address ❑ PACKAGE PLANT _ <br /> ❑ SEPTIC TANK ❑ CESSPOOL 'LEACHING FIELD Ot SEEPAGE PIT 11 CHEMICAL <br /> ' <br /> E3 PERMANENT 11 TEMPORARY 13 NEW REPAIR <br /> S. CHEMICAL TOILETS For July 1,-June 30, 19 . � <br /> Type Construction Disposal Site Q <br /> No. of Units Equipment Storage/Cleaning Location(s) O <br /> ' S. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19 (� <br /> Where Certified r <br /> Operator Name <br /> Plant Location No. Units Served <br /> ' Plant Capacity „ <br /> T. ❑ LAUNDRY For July 1, -June 30, 19 W <br /> SIZE: ❑ Less Than 1,000 Sq. Ft,,, ❑ More Than 1,000 Sq. Ft. �y <br /> ' ❑ DRY CLEANING,Chemicals Used/Amount/Mo. - ro <br /> pparea awnerbrneenced agent's signataraeartlterthain::o�+dnh+"I Ceti",that in the parlormanceot thewark torwhich this permit is lssued.l shat)not employ anyparsoR <br /> i,such manner as to corr.p1matiou lows CSC ilcrnl2.' <br /> Conuaetor's biting or aubrocn:rac'Gng si•roaitiro aetFnz•the following: "I cattily that in the performance of the work for which this permit 15 issued,I shall <br /> employ persons subject to workman•s comoe,IsatioR laws d Calif0cme :ac <br /> with San Joaquin County <br /> ' - t I hereby certify that I have prepaied this application and that the work will be one in ac <br /> ordinances,state laws,and rule a ulatjg f t e San quin Local al QWrct. <br /> ------------- <br /> APPLICANT'S SIGNATURE X r <br /> t FOR DEPARTMENT USE ONLY. — <br /> ' <br /> Fee IS Due: 13 ANNUALLY ❑PER UNIT ❑ PER SITE 13 EACH El January 1 8 Received By January 31 ❑ July 1 &Receiv REMITu!y 31 <br /> BILLING REMITTANCE 'S AMOUNT DUE CHECKED <br /> EXPLANATION <br /> BASE BILL <br /> REMITTED AMOUNT <br /> DATE-p"L-. — ....... . _ .a . . <br /> ' FEE. .... - <br /> LESS <br /> PRORATION <br /> PLUS <br /> ' PENALTY — <br /> s <br /> DTHErI ' <br /> ,. OTHER <br /> ReceiPt No. Permit No..' Issu ce Data Mailed Delivered <br /> ReAPPLI by Date '1601 E.HAIELTON AVE.,P.D.eat 2009 eTOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES /Je<-d G� <br />