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d Properly <br /> Applications Will Be Processed when SuAPPLICAT1QIVp e e e <br /> {For Non-Transferable, Revocable,and Suspendable} SEpTAGE <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> r LIWASTE' <br /> App l icatio h y e t carry on Hess' t jQUID urisdictional area of the Sa ` �aquin al H alth Distri <br /> 11��ss <br /> rn Business BAS Address (p <br /> a Owner r C' l� <br /> r c 6 TFL <br /> 0 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. '��3 3 <br /> 0.a <br /> Contractor Licence No. S 7� Gej,tr Dated <br /> Applicants Name (Print) r <br /> Title <br /> Please check Applicable Category.(1-7)and Fill in the Required IMorMation t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> CAL, License No. <br /> Serial No. I <br /> - Gal.,Weights & Measures No. <br /> Capacity <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 R.S. or R.C.E. No. <br /> R.S. or R.C.E..Name Test Date/Time <br /> Test Location I <br /> q. WSANITATION PERMIT� ZAcz, ' <br /> Job Address Loca{ion Address `s <br /> OwnerElPACKAGE PLANT <br /> C SEPTIC TANK 13CESSPOOLCEACHING FIELD IEEPAGE PIT ❑ OTHER <br /> ❑ TEMPORARY B'NEW 13REPAIR <br /> ��ERMANENT i, <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> i <br /> f Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> � <br /> g, ❑ P 1, - June 30, 19 ACKAGE TREATMENT PLANT For July Where Certified <br /> Operator Name <br /> Plant Location No, Units Served <br /> Plant Capacity 0 <br /> 4 7, ❑ LAUNDRY For July 1, -June 30. 19 <br /> Than 1,600 5q. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> ( n d that he work will be done in accordan h S n J a in County <br /> I application <br /> I hereby certify that I have d this app uin Local Health District. <br /> ordinances, state laws, a rules d re ulations of e n rtrt <br /> APPLICANT'S SIGNATURE X I 1 <br /> { FOR DEPARTMENT USE ONLY <br /> - ❑ ❑ ❑ PER SITE ❑ EACH El January 1 &Received By J uary 31 ❑-July 1 &Receiv REMITd By uly 31 <br /> Fee IS Due: ANNUALLY, PER UNIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> - BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> Q <br /> FEE <br /> 4 S 4y <br /> LESS + <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> 9. <br /> OTHER <br /> Receipt No. _ Permit No. Is uance Date rile Delivered <br /> i. Received by__ - pate - 1601 E.HAZELTON AVE.,P.O.Box 2009' <br /> STOCKTON,'CA 95201 <br /> r APPLICANT—RETURN ALL COPIES TOi ,ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />