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toebure 10 01mil. <br /> App Will Be Processed When Submitted pLICAT�ONe e ' <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> �r 3 ENVIRONMENTAL HEALTH PERMIT <br /> r LIQUID WASTE juin �J <br /> Application is erebyFinade to arry on busi ess in the]' risdi ionaare <br /> Addressthe®JoLo`a�H th District <br /> wBusiness Name(DB Address <br /> aOwner <br /> e u Firm Partners, Addresses and Telephone Numbers 1 <br /> r11. dsf' Emergency Telephone No. <br /> A. <br /> Business Telephone No. 2 �� C <br /> Contractor Licence No. .� Date <br /> Title <br /> 7rt�� <br /> Title <br /> LApplicants Name (Print) <br /> Please check Applicable Category(1-7)and Fill in the R uired information <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 /> Serial No. CAL. License No. <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 LL ation <br /> 4, 1� SANITATION PERMIT <br /> Job ddresslLo ion Address <br /> O ner ❑ PACK GE PLANT <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT C1 OTHER -� <br /> 11 PERMANENT 13 TEMPORARY ❑ NEW REPAIR <br /> 0 <br /> i 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30,'19 Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. r <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I 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 rul nd regulations Of tSa Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> I FOR DEPARTMENT USE ONLY <br /> k <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Receivend Byyl Juky 31 **�\ <br /> BILLING REMITTANCE $ AMOUNT DUE_ CHECKED <br /> EXPLANATION <br /> BASE DATE DATE REMITTED AMOUNT <br /> FEE S <br /> LESS <br /> PRORATION <br /> PLUS <br /> f PENALTY <br /> OTHER <br /> OTHER <br /> 3a (o <br /> Received by <br /> Date Receipt No Permit No. I u ce Dae Mailed Delivered <br /> .APPLICANT—RETURN ALL COPIES TO:' ENVIRONMENTAL HEALTH PERMITISERVICES 1801 E.HAZELTON AVE.',P.O. oa 2009 STOC ON,CA 95241' 9 <br />