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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transierable, Revocabie,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereb made to carry on business in the jurisdictional area of the San J2&quin Local Health Distr�t <br /> F Business Name (DBA) Address - � — <br /> z Owner . Address <br /> c <br /> J Firm Partners, Addresses and Telephqne Numbers = <br /> iCL <br /> Business Telephone No. � Emergency Telephone No. <br /> Contractor Licence No. f Y f <br /> L Applicants Name (Print) Title Date ^` "` 0 <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=LDisposal Sites " <br /> p - -- <br /> Description(Make/Yr., Color) <br /> LL -1...'e.�._ u-.:,.-„�r-:»�...�,.... --. �-� GAL:Lir>eRse RenewaWSla <br /> Serial No. �' CR1�"`t-"tCertse'No. <br /># Capacity : Gal.,Weights &Measures No. fi <br /> Equipment Parkinig Address <br /> 2. ❑ PUMPER YARD t <br /> F For July 1, June 30, 19 <br /> No. of Vehicles Stored 3 <br /> No. of Chemical Toilets Stored <br /> 7. <br /> 3. ❑ PERCOLATION TESTi t <br /> R:S. or R.C.E. Name R.S.or R. .E. No. f a <br /> { /} Test Date/Time <br /> Test Location { ` � s :I <br /> } 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner �1 <br /> I d ,y= 1 Address <br /> EPTIC TANK ❑ CESSPOOL ACHIN(2 MELD "�,'SEEPAGI= PIT PACKAGE PLANT l <br /> 11 PERMANENT' ❑ TEMPORARY ❑ NEW ii ❑ REPAY #1 ( .CJ OTHER <br /> CA <br /> 5. © CHEMICAL TOILETS For July 1, -June 30, 19 r � S <br /> Type Construction Disposal Site x <br /> t No. of Units Equipment Storage/CIean�g Locations) { <br /> fi. ❑ PACI(AGE TREATMENT PLANT For July 1, -Jur�e'3;0,�19 ; .. ., I <br /> Operator Name �- Where Certified — j - <br /> Plant Location <br /> Plant Capacity k No. Units Served <br /> 7. ❑LAUNDRY For July 1, -June 30, 19f r - <br /> SIZE: ❑ Less Than 1,000 Sq. Ft.,r ❑.More Than 1,000'fBq.�5t. <br /> 11 DRY GLEANING, Chemicals Use 7A dnt/Mo, ' } <br /> I hereby certify that I have prepared'this applicatiom and that the work will be done in accordance with Sart Joaquin County <br /> ordinances, state laws and rules and r ulations of�h S Joaquin Local Health District. I <br /> APPLICANT'S SIGNATURE X <br /> 4 11.,,.,-_._—FOR=DEPARTMENT USE-O'I`#tY <br /> Fee l5 Due: ❑ ANNUALLYli" ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January-31 ❑ Jluly 1 &Received By July 31 <br /> BILLING REMITTANCE $ I REMIT UE CHECKED <br /> BASE EXPLANATION AMOUNT D <br /> - DATE DATE REMITTED I AMOUNT <br /> Ll <br /> FEE 3 <br /> LESS <br /> PRORATION' <br /> PLUS <br /> PENALTY <br /> OTHER_-._..=...�....... -- - - „----•�-•.. <br /> Received by Date ' Receipt No. Permit No. - Issuance Date Mailed Delivered <br /> 1b111 E.HAZELTON AVE-,P.O.Box 2009 5TOCNTON,CA <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PERMIT/SERVICES 95201 <br />