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Applications Will Be Processed When Submi tteed Properly LICATIONpleted. tiesure 1V �w- <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applic is hereby a to carryon business. lh Iurisdictional area of the San Joaquin Heal Dis ict <br /> ��^ rJI�F Address <br /> W Business Name {DBA} /P'" Address <br /> i Owner <br /> 4 <br /> Firm Partners, Addresses and TelephoneI 110 11"Numbers Emergency Telephone No. <br /> I <br /> CL <br /> Business Telephone No. Ift Ir d Z <br /> 1 Contractor Licence No. Title 11/ Date i <br /> L Applicants Name(Print) <br /> Please check Applicable Category (1-7)and Fill in the Require 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 /> CAL. License Renewal No. <br /> Serial No. GAL. 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 Location <br /> a. KSANITATION PERMIT / <br /> I� <br /> Job Ad dr Location ft4V- <br /> Owner11 C3LERCHING FIELD SEEPAGE PITPACKAGE PLANT <br /> 11 SEPTIC TANK C1 CESSPOOL REPAIR 13 OTHER <br /> L <PERMANENT C3 TEMPORARY 13 NEW 1 <br /> Q <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, ipisposal Site <br /> Type Construction <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 LocationS <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30,19More Than 1,000 Sq. Ft. <br /> SIZE: 11 Less Than 1,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 hereby certify at I h e pre ar fe i ulaappohcati the S thaqLhe <br /> oaqu work ill a be <br /> done <br /> i District. <br /> accordance with San Joaquin County <br /> ordinances, state laws, an g P <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE El EACH [I January 1 &Received By January 31 ❑ July 1 &ReceivedREMIT <br /> uIy 31 <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT. <br /> FEE <br /> LESS <br /> PRORATION t <br /> PLUS /f <br /> PENALTY <br /> OTHER <br /> OTHER O <br /> Date Receipt No. Permit No. <br /> Issu nce Date Mailed Delivere <br /> .Received by 1601 E.HAZELTON AVE.,P.Q.Box 2009 STOCK ON,GA 9 201 <br /> Y <br /> APPLICANT ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITlSERVICES 4 <br />