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Applications Will Be'-Processed When Submitted Properly Completed. Be Sure To Sign The Application <br /> f -w APPLICATION ' <br /> (For Non-Transferablef Reroeable,'and Suspendable) SEPTAGE <br /> s.ENVtA.ONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the�an Joaquin Local Health Distric <br /> y Business Name �DBA)�« fife l GSC� 6 f; C� ,Address .Al 01. <br /> a Owner ' L / Address 65- fes' <br /> Firm Partners, Addressesnd Tele hone Numbers <br /> IL Business Telephone No . r Z21 : <br /> v <br /> a Emergency Telephone No. <br /> Contractor Licence No. ( y <br /> L Applicants Name (Print) I3�? /g' �j Title -...Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - - June 30,19• Disposal Sites - <br /> Description(Make/Yr,-Color) <br /> Serial No. � � "� - "-7-CAL-Licens6-N0:' - ---a-- -- .CAL-Lie nse R6newal No. <br /> Capacity I <br /> P Y Gal-, Weights &Measures No. ` } <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD . ; <br /> For July 1, June 30, 19 °} -L .> �.S ':# 'W\ <br /> No. of Vehicles Stored I <br /> } <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> t <br /> R.S. or R.C.E.Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4�SANITATION PER IT A�`` , <br /> Job Address/Location Jul I— L0 4-3 <br /> Owner Address f <br /> tRL6EPTIC TANK(' ❑ CESSPOOL jir-tEACHING FIELD j lli -EEPAGE PIT ❑ PACKAGE PLANTS <br /> ❑ PERMANENTS ❑ TEMPORARY ❑t NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19th <br /> Type Construction Disposal Site I r <br /> No. of Units i Equipment Storage/Cleaning Location(s) Et <br /> 6. ❑ PACKAGE',TREATMENT PLANT For July 1, -June 30, 19 rt <br /> Operator Name -1 E Where Certified <br /> Plant Location. _ t <br /> Plant Capacity r^ _ No. Units Served ' <br /> 7. ❑ LAUNDRY t For July 1, -June 30, 19 <br /> SIZE: ❑ Legs jThan 1,000 Sq. Ft., ❑ More Than 1.,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used%AmounUMo: <br /> I hereby certify that Ihav re'pared this application and that th rk Will �e done in accordance with San Joaquin County <br /> Ordinances,'state laws, a rules alb, regu ions of the an Joa i cal Health District. / <br /> APPLICANT'S SIGNATURE X .1� V <br /> I <br /> FOR DEPARTMENT-USE bNLY f cy <br /> Fee Is Due:; UALLY ❑ PER UNIT ❑ PER SITE� _❑_EACH ❑ Jarfua y 1-"eC*Wed.�tyaruary 31a r ❑ July 1 &Received By Ju'y <br /> 31 <br /> t-R <br /> BASE EXPLANATION BILLING REMITR'ANC_E ;, $. _ REMIT <br /> -111,�f`- jOAT$`�-. . '� DAT -'-"REMITTEEb ....� MOUNTBUE CHECKED <br /> r - AMOUNT.- <br /> FEE E 2.4 JFK 1 (\ <br /> P + V <br /> LESS i l <br /> PRORATION fl 11 C- V i„�`,�- {.i1 <br /> PLUS <br /> PENALTY F1,�r --•.. `,� - <br /> OTHER <br /> OTHER <br /> Received by11 D to V Receipt No. Permit No. Issuance to ailed - Delivered <br /> APPLICANT!!:RETURN ALL•COPIES TO:--ENVIRONMENTAL-HECES— ^-1601 E.'HAZEL-TO -P f Bo 2009 STOCKTON,CA 95201 <br />