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-Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> M (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> .-ENVIRONMENTAL HEALTH PERMIT <br /> .,j <br /> LIQUID WASTE / <br /> Application is,,lereby made to carry on business in the jurisdictional area of the San Joaquin.Local Health District _ <br /> OF Business Name (DBA) .+Qd 1✓ k Address �l .-- G ! TZ <br /> z Owner A, Address <br /> u Firm Partners, Addresses and Teleph a Numbers <;z <br /> C6 Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) .--' Tw0 Title Z7 Date <br /> Please check Applicable Category (1-7)and fill in the Req "ired Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) y ) <br /> For July 1, June 30, 19 - Disposal Sites <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 Ch:emiCal Toilets Store <br /> 3. ❑ PERCQLATION TEST <br /> I , <br /> i` R.S. or R.C.E.SName } Fi S�Qr F1 C E._No._... ".. __ ��,b�a Ilk <br /> Test Location' Test Date/Time <br /> t <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Lo ation <br /> OO,wn Address , , }+ - ,_P� <br /> t1�'SEPTIC TANK ❑ CESSP..00L___; .ACHING FIELD 11PA <br /> SEEGE PIT-❑-PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ! LNEV41 ❑ REPAIR ❑ OTHER <br /> 5. _❑ CHEMICAL TOILETSt;_rFoF July_1,_June�30s 19 { i <br /> Type Construction Disposal Site °.� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 3Q, 19 W J <br /> Operator Name here.Certified:-- -- -_--- <br /> Plant Location <br /> Plant Capacity + No. Units Served - <br /> 7. ❑ LAUNDRY • For July 1, -June 30, 19 _ <br /> SIZE' ❑ Less Than 1,000 5q. Ft., ❑ More Than 1,000 Sq. Ft. `� ""�"" <br /> .❑ DRY CLEANING, Chemicals life_& mount/b/lo. <br /> _ ( `` I f �FI I � ft .I ��u.w .•-1:-,-..-.a•.r-Y. .1�..�Yr�:YV,. •y.�Kanw'� dn'v' ^,- <br /> I hereby certify that i have prepared this applicattd'that the work will be done in accordance with San Joaquin County <br /> ordinances.state laws, and rules and reg6lf 'Y ns of a�r1'jJaaq in-Local-Health District-.-; <br /> APPLICANT'S SIGNATURE X '-✓ ' <br /> . - F,60 6EPAFt•?MEt3T USE ONLY <br /> Fee Is Due:.[] I�I <br /> AVALLY ❑ SER. UNIT] 11 PER SIN ❑ EACH l LJ January 1 &Received By,Januacy 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASF EXPLANATION , <br /> BILLING REMITTALCE $ I AMOUNTDUE CHECKED <br /> ? I � <br /> AMOUNT <br /> FEE - <br /> v 6 <br /> LESS <br /> PRORATION <br /> PLUS t #, i <br /> - PENALTY <br /> T OTHER _ - •, .r ��I:4 ; !t•`,'y. >.. -- - - ---•- <br /> -- <br /> OTHER <br /> • _ " � - - <br /> Received by Date Receipt NOL' Permit No. I suance ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'HEALTH PEAMITISERVICES 1601 E.HAZELTON AVE.,P.O.'Bax 2009 -STOCXTON,CA 95201 <br />