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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> t v (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is reby made to arty on business in the'uris is ' nal area of the§ag aquin LoCal Health Distric <br /> OF Business Name (D ) � �, '7-62 <br /> 7Address- {� � <br /> i Owner Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency'Telephone No. <br /> Contractor Licence No. Z 2- Z a <br /> L Applicants Name (Print) Title Date l "� 8a { <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 'Ij <br /> For July 1, June 30, 19 Disposal Sites F <br /> Description(Make/Yr., Color) Nk - <br /> Serial No. CAL. License No. CAL. License Renewal No. - <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking'Address - <br /> 2. ❑ PUMPER YARD T <br /> .c <br /> For July 1, June 30,-19—'� ` <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored - <br /> 3. ❑ PERCOLATION TEST QJ <br /> or R.C.E. No. <br /> R.S. or R.C.E. Name �R.S4_ 1 � ` 0 <br /> Test LLO ation '_ � .Test Timg 4r <br /> 4. Iia SANITATION PERMIT <br /> Job Address/Location ,6 <br /> Ow9er 47 ( Address <br /> IC TANK ❑ CESSPOOL ACHING FIELD— 1:1 PACKAGE PLANT <br /> LQ PERMANENT ❑ TEMPORARY BINEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,- June 30, 19 <br /> Type Construction Disposal Site , <br /> No. of Units Equipment Storage/Cleaning Location(s) fA4 <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 /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING;Chemicals Used/Amount/Mo. a '— <br /> N. <br /> 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 rules a regulations of the S n Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> _ FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received July 31 <br /> IT <br /> BASE ti „EXPLANATION BILLING REMITTANCE $ AMOUNT DUE ECKEO <br /> DATE DATE REMITTED AM T <br /> FEE <br /> LESS y �� <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Receipt No. permit No. Issuance pate Mailed Del er dReceipt No. Permit No. Issuance Date Mailed Del er d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 - <br />