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Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> d LIQUID WASTE <br /> y . Applictio rebyfmadet c n bu i io areraeosfs the an aq LocaHeDis <br /> siness Name dd <br /> Owner Address &sa6+f <br /> Firm Partners, Addresses and Telephone umber —._ —__.— <br /> Business Telephone No. Q��I -- Emergency Telephone No. <br /> -+Contractor Licence No. <br /> L Applicants Name (Print) __ Title _ Date <br /> Please check Applicable Category(1-7)and Fill In the Required 4formation 0 <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1,--June 30, 19 Disposal Sites ..__........... <br /> .__ -- <br /> Description(Make/Yr.,Color) -..- <br /> Serial No. CAL. License No. _ ____.___CAL. License Renewal 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.or R.C.E. Name R.S.or R.C.E.No. <br /> Test LL ation Test Date/Time <br /> 4. LS SANIT ION PERMIT <br /> Job Addres /Loc do — <br /> �'` a <br /> Ow r Addresccs--,,�.� � ❑ PACKAG LANT <br /> OPTIC AN ❑ CESSPOOL EACHING FIELD cr5t E PIT 0 ) <br /> L'� PERMA ❑ TEMPORARY NEW PAIR 11 OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> )e Construction Disposal Site m <br /> ,.o. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Operator Name _ __ Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZES ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. --- <br /> D <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with Joaquin County <br /> ordinances,state laws,and rules an regulations ofthe J quin Local Health District. ; <br /> APPLICANT'S SIGNATUREX <br /> j 1'R <br /> FOR DEPARTMENT USE ONLY { 'u <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 1342 ey January 31 ❑ July 1 8 Received By July 31 <br /> BILLING REMITTANCE . $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE EMITTED <br /> AMOUNT <br /> FEE --- -- O . : L5 <br /> LESS ii <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> — _ x <br /> OTHER <br /> f" <br /> OTHER <br /> Received by Date Receipt No. Permit No.v Issu nce Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2006 STOCKTON,CA 95101 <br />