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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />PFP APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA) Address <br /> Rod�lir-re L. N EfynlA+JDGL Qv. 1• UI.Y:R rt !/� u7 3b + � <br /> Owner Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> Y Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) �d� !�tLZ*4e..4 Title Date <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 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 0emical Toilets Stored <br /> 3. ;;PERCOLATION TE <br /> Z.S. or R.C.E. Nam �7 l��Z R.�r Fi,�C.E. Na <br /> est Location <br /> �-- /Ti <br /> T st Dateme( <br /> OF <br /> ❑ SANITATION PERMIT <br /> ti Address/Location <br /> Address <br /> ner 11 PACKAGE PLANT <br /> SEPTIC TANK C3 CESSPOOL C3 LEACHING FIELD C1 SEEPAGE PIT C1 OTHER <br /> 'ERMANENT 11 TEMPORARY 1:1NEW C1 REPAIR <br /> 7 CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Construction Disposal Site <br /> Units Equipment Storage/Cleaning Location(s) <br /> 1 PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> 1r Name <br /> cation <br /> No. Units Served <br /> oacity <br /> UNDRY For July 1, -June 30, 19 <br /> :3 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ;LEANING, Chemicals,`Used/Amount/Mo. <br /> I hereby certify that I have prpared this applica4n and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws �d-W.1es arr10reguWWns of San Joaquin Local Health District. <br /> AANT'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 &ReceivedREMITuly 31 <br /> EXPLANATION BILLING REMITTANCE $ ! AMOUNT DUE CHECKED <br /> BASE DATE DATE REMITTED AMOUNT <br /> IEE <br /> PRO'.'TION <br /> PLUS <br /> PENkn <br /> OTHER <br /> OTHER <br /> E - ----% ` <br /> Recei t No. Permit No. Issuance Date Mailed Delivered <br /> Received oy Date P <br /> 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br />