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Applications Will Be P ased When Submitted ProGPleted- Be Sure TO Sign The Application. <br /> ( APPLICATION <br /> (Far Non-Transferable,Revocable,and Suspendaole) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ❑QUID WASTE <br /> Application i ereby madejp carry on bu iness in thikjurisikictional area of the San Joaquin Local Health District <br /> Address <br /> n Business Name (D ) <br /> r Owner Address <br /> 4 <br /> 3 Firm Partners,Addresses and Telephone Numbers <br /> i Business Telephone No. 361, <br /> `��OS Emergency Telephone No. <br /> i ff Zz6 Contractor Licence No. Date <br /> �Applicants Name(Print) Title J <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) CAL. Liccnse Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal..Weights &Measures No. <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 <br /> 3. ❑ PERCOLATION TEST <br /> R.S. .S.or R.C.E.No. <br /> .S. or R.C_E. Name <br /> Test Lq�atiOn Test{]ate/Time <br /> 4. W SANITATION PERMIT <br /> Job Address/Location (p`> 1Fa <br /> Ow er Address_ yb <br /> 7SS£PT1C TANK 11CESSPOOL ;.ACHING FIELD - T ❑ PACKAGE PLANT <br /> PERMAN7=N7 ❑ TEMPORARY NEW ❑ REPAIR 1:1 OTHER <br /> CHEMICAL TOILETS For July 1,-June 30, 19 C <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. 13 LAUNDRY For July i,-June 30, 19 <br /> SIZE: [3 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. f4 <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 rule and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Fee Is Due: © ANNUAy LV ❑ PIER UNIT PER SITE ❑ EACH ❑ January 1 8 Received 13y January 31, 0 July 1 8 eceived By REMITuIy 31 <br /> BASE E%PLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> GATE DATE REMITTED AMOUNT <br /> FEE � J <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER n <br /> OTHER , <br /> nate Receipt No. Permit No. I arae to Mallad Delivered <br /> Received by ' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICE9 7801 E.HAZELTON AVE.,P.O_aox Y009. 6TOCKTON,.CA g8R0f <br />