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AppfcatibiiiWlll Be Processed When Submitted Properly Completed, Be Sure To Sign TheApplication. <br /> o- ) b ), 6 APPLICATION <br /> 6 (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> 12 4 ENVIRONMENTAL HEALTH PERMIT <br /> ` LIQUID WASTE <br /> Appl icati is ereby �et �arryonA�sinessJn the jurisdictional area of the San Joaquin L al H It is <br /> rn Business a (D8 } <br /> Address S <br /> i Owner Address <br /> a <br /> 0 Firm Partners, Addresses and Tele onre`Nu bers <br /> aBusiness Telephone No J� � r Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required ntormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 L Disposal Sites 0�) <br /> Description(Make/Yr., Color) I 0 <br /> Serial No. CAL. License No. CAL. L'ccnse Renewal No. ) <br /> 1 <br /> Capacity Gal.,Weights & Measures No. A <br /> Equipment Parking Address ) vl t <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 <br /> R.S. or R.C.E. Name R.S. or R.G.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERM T <br /> Job AddresElRocation 4 6 , <br /> Owner OF Address <br /> 13p SEPTIC TANK ❑ CESSPOOL LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT <br /> IMPERMANENT ❑ TEMPORARY ❑ NEW XREPAIR ❑ OTHER l <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br />! Type Construction Disposal Site <br /> No. of Units Eg6pment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> r <br /> Plant Capacity No. Units Served <br /> _ <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> 13DRY CLEANING, Chemicals Used/Amount/Mo. <br /> x <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 and reg Pat. s of the an Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X • <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11may.ANNUALLY ❑ PER UNIT P PER SITE ❑ EACH ❑ January 1 8 ived January 31 -❑ July 1"&Received By July 31 <br /> REMIT <br /> RASE EXPLANATION BILLING REMITT NCE AMOUNT DUE CHECKED <br /> DATE DA REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt N _ Permit No. Issuance Date Mailed - Deliver d <br /> 1601 E.HAZEL70N AVE.,P.O.BOR 2009STOTON,CA 201 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - . C <br />