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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION i <br /> 1--� (For Non-Transferable, Revocable,and Suspendable) <br /> /I SEPTAGC <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ILIQUID WASTE <br /> r Application i heret)y�made o carry on business in the jurisdi tional area of the San oaq�uiinLocal Health Distn <br /> Business Name (DSA Address— <br /> in <br /> ddress7 <br /> i Owner Address �— <br /> a <br /> J,Firm Partners, Addresses and Telephone Number <br /> QBusiness Telephone No. ;z -� O 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 Information <br /> a <br /> 1:-O'PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) f <br /> For ^July 1� June 30;19 Disposal Sites t <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address - -" <br /> 2. ❑ PUMPER YARD 'y <br /> t 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.C.E. No k. <br /> TeskANITATION <br /> ation _ Test.Date/Time <br /> 4. PERMIT <br /> Job Address/Location t <br /> Owryer Address S <br /> f �5 PTIC TANK ❑ C SPOOL LL HING FIELD ❑ PACKAGE PLANT <br /> i LfYPERMANENT ❑ TEMPORARY NEW �Aj ❑ REPAIR �❑ OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 1 � i <br /> Disposal Site � <br /> � Type Construction - - <br /> I <br /> No. of Units Equipment Storage/Cleaning Locatioi (S)� <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30;1$ wos <br /> Operator Name Where Certified <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity tw <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 + <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. F0; <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> _ f <br /> l + � i� <br /> I �1 <br /> I hereby certify that I have prepared this application and that the work will be done i ordance with San Joaquin County <br /> ordinances, state laws, and rules regulations oft an Joaquin Local Health Distric . <br /> APPLICANT'S SIGNATURE X - <br /> FOR DEPARTMENT U O <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ElPER SITE El EACH ❑ J ry 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE - EXPLANATION BILLING RE ITT CE $ AMOUNT DUE CHECKED <br /> DATE AT REMITTED AMOUNT <br /> FEE f~ <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> L <br /> i OTHER <br /> OTHER <br /> a C�SW�(3 _�/�7 <br /> ` Received - ' Issuance Date Date Receipt Na Permit No. ailed Delivered <br /> }' APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 5TOGK70N,CA"85291 ' <br /> \ E <br />