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Applications Will Be Processed When Submffled Properly Completed.Be Sure To Sign The Application <br /> APPLICATION <br /> -" (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE " <br /> Applicationy•�is hereby de to carry on b sin ss in the jurisdictional area of the an Joaquin Local Health District <br /> -usiness Name{DBA) .(_✓r A. algish- 0ryr Address P• "0X zif��.��Zt�f <br /> a OwnerAddress <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 4ZJ6 Emergency Telephone No. <br /> Contractor Licence No. <br /> a Applicants Name (Print) /r��ie1.4s1'e-1 �ca�r�� Title, .f_ — _ - _ Date-19 a-�l <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 No. _...______—_ WLcenseI No. t_. •-• <br /> Capacity Gal.,Weights&Measures No. <br /> Equipment Parking Address 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored t <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name ` R .or R.C. 'No. <br /> Test Location " /T• 1 r <br /> 4. Of-SANITATION PERMIT " •, <br /> r <br /> Job Address/Location o <br /> Owner r ddress <br /> SEPTIC TANK ❑ CESSPOOL LEAC NG IELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT �t ' 1 • <br /> ,® <br /> PERMANENT' TEMPORARY NEW T❑ REPAIR' ❑ OTHER t • <br /> r' ❑ CHEMICAL TOILETS For July 1,-June 30 19_..... <br /> ._ <br /> pe Constructiona ey,� t Disposal Site ' <br /> No. of Units. ��• � _ z ;Equipment Storage/Cleaning Location(s) - 4 <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 �. +" .a - •,` i <br /> Operator Name• ' WhereCertified .« <br /> ` <br /> Plant Location _ '• <br /> Plant Capacity__ ` No. Units Served <br /> 7, 11 LAUNDRY For'July 1, June 30, 19' <br /> SIZE: ❑ Less-than 1,000 Sq. Ft., J'❑ More Than1,000 Sq. Ft, 9• -.�W i` <br /> ❑ DRY CLEANING,Chemicals'Used/Amount/Mo.- �r — <br /> Homno�wnerorticonaedagent'ssignAtu•ecwtifieKthefollOin!tiop!}r16TR11PCo�Ifli,,,werkforwhlrhINSptririltial®s1)a l'hfl.11[tOtG•m 14yt1(1yP@"" <br /> in such manner as to become subject tc vrorkn+a: c^ <br /> s m{mn,atim;'alys ol+laiitarnia:' <br /> Ccntm<.tor's hiring or sub•controoting 9ipnntclrri ro+tifios ehe follovoi»4' I F"'flily thl,111 Iho p0crm"Ince 0i the viork for Wlilb 11111q p0l Milt t t 156Uc1i,1 dilall <br /> � _ !-emkl�y persons sun)ac;to v+olkrrads corrlp0nsatiart iarfs of California." t :� '•l-, "s <br /> ti j •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 r I r1d r guI tion3 of the Sa oaq n Local Health District. <br /> /j <br /> APPLICANT'S SIGNATURE X - <br /> T <br /> I _ <br /> ` FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH_ ❑ January 1&Received By January 31 ❑ July i &Received By July 31 <br /> • BILLING REMITTANCE $ REMIT <br /> BASF EXPLANATION AMOUNTDUE CHECKED <br /> .DATE —DATE REMITTED. t + AMOUNT ' <br /> FEE &46;/ K,,Y;LESS <br /> PRORATIONPLUSPENALTY <br /> OTHER _ <br /> tj <br /> OTHER ' <br /> - - -- <br /> tS3� � _ � . <br /> Received by Date Re.eipl No. Permit No Issu nse D e pled Delivered <br /> APPLICANT—RETURN ALL COPIES Tot ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON ,P.O.Box 20 — N,CA 95201 <br />