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�i Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application.
<br /> (� APPLICATION
<br /> (For Non-Transferable;Revocable,and Suspendable) SEPTAGE
<br /> ENVIRONMENTAL HEALTH PERMIT
<br /> LIQUID WASTE
<br /> Applic i n is hereby madet car n bu in s in tj=Address of the�rq aq Local Health District
<br /> fBusines �arnneDB Address �+
<br /> a Own Address -
<br /> Firm Partners, Addresspanelep,one Nu err,aBusiness Telephone NoEmergency Telephone No.
<br /> Contractor Licence No.
<br />�a=Ap151icfints,Namer Print L (� Title DatPlease check Applicabl -7).and Fill in th RequiredInfarmatlon n t
<br /> 1.~ CI`PUMPER'3/EHICL'E'PERMIT REGISTRATION (FOR EACH VEHICLE) i }
<br /> w
<br /> For July 1, June-30,19 Disposal Sites
<br /> Description(Make/Yr.a Color)
<br /> Serial`No."4` �9" CAL. License No. CAL. License Renewal No.
<br /> Capacity . . Gal.,Weights & Measures No.
<br /> Eq uipment-Parking,Addr;e`ss
<br /> 2. ❑ PUMPER YARD —
<br /> i r
<br /> For July 1, June 30, 19
<br /> No. of Vehicles Stored
<br /> No. of Chemidai,Toilets Stored
<br /> 3. ❑ PERCOLATION.TEST
<br /> R.S. or R.C.E.Mame R.S. or R.C.E.No.
<br /> Test�Loc fDn Test Date/Time
<br /> 4. L7 SANITATION PEE T,./
<br /> Job Addre /location'
<br /> Owner Address Z
<br /> ❑ S�FTIC TA -CESSPOOL --LEACHING FIR0- -SEEPAGE PIT❑-PACKAGE,PLAN,
<br /> ®/PERMANENT ❑ TEMPORARY ❑ NEW 9 REPAIR, ❑ OTHER r'
<br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 -.d ''j` 1 .J01)
<br /> TYPe�Construction — Disposal-Site
<br /> NO. of Units Equipment Storage/Cleaning Location(s) T^w�
<br /> 6. PACKAGE TREATMENT PLANT For July 1, -June 30,119
<br /> �h
<br /> Ope ato"r Name _ "�'�. �� , � Where Certified
<br /> Plant`L-oc tion' • Fz u
<br /> Plant Capacity: NOnits Served
<br /> 7. ❑ LAUNDRY For July 1, -June 30_19
<br /> SIZE: _❑ Less Than 1,000 Sq. Ft., ❑1More Than 1,000 Sq:,Ft: s
<br /> © DhY CLEANING, Chemicals Used/ArAou`nt/Mo. A F
<br /> +eew finer as to h c ome su's signature,m 'flea the follower+a;'i cerfify4 h_a the performance of the work for which this PefM t is isst3ed,I shat!not empi a
<br /> in suefs maftner as to become Suhiect to.nor!i7ail's c3rlpensai ten Is v!Cali,a;n a:' p oY ny perso
<br /> Mp:Conl y pe a hiring.qr sttd•COn1taC+:n_r. sigtlaEt. �err;i e.; .+P, fotEosri f cr'ify*hat in the'Per' of Me work for Aich this permit is issued,f shall I
<br /> elnploy Persons st�;ec 10 r;cr!,n ;._,rsr, ,,s ;iolry,f C41f:4in. . a
<br /> �_l hereby certify that I have prepared.this'application and that°the work will be done iri accordance with San Joaquin County
<br /> I-otdinances, state laws, d rules and ulafons of the S h Joaquin Local Health District.
<br /> APPLICANT'S SIGNATURE X 7 -
<br /> L.f. '
<br /> _ Gy FOR,DEPARTMENT USE ONLY
<br /> Fee Is Due: 13ANNUALLY ❑ PER UNIT ❑ P&SITE�a;. t. ❑ EACH, ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31
<br /> f 1 REMIT
<br /> t.- BASF= /EXPLANATION BIL`LiNG REMITTANCE $ AMOUNT�� DUE CHECKED DATE DATE REMITTED
<br /> AMOUNT
<br /> FEE r
<br /> LESS
<br /> PRORATION b.., ° q • V
<br /> c
<br /> PLUS
<br /> y� PENALT
<br /> r OTHER S
<br /> i r
<br /> OTHER
<br /> Received by I Date Receipt No Permit No Issu nce to Marled _ Delivered
<br /> j j�;a/ �
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITfSERVICES " 1601 E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON,CA 95 01
<br /> LY D,,- �7 ;-2
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