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__ f <br /> Submitted Properly Completed. <br /> Applications Will Be Processed When <br /> APPLICATION <br /> (For Non-Transferable,'Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the§ao J0a5{"A Loca H . 2pigtrict <br /> �kdd resS <br /> yBusiness Name (DBA) Address <br /> aOwner - <br /> Firm Partners, Addresses a Te ep�hop um rs Emergency Telephone No. 3 <br /> CL Business Telephone No.. 1 <br /> r <br /> Contractor Licence No.. :-_ f Title ate <br /> L Applicants Name (Print) ._ ._ <br /> 1 7 and Fill in the Required Information <br /> Please check Applicable Category-( - )_ <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOA EACH VEHICLE) <br /> n'For July 1, June 30 19-L, <br /> -- <br /> — _ -Disposal Sites. - =" <br />,i�- Description(Make/Yr.,Color) CAL. License NO. CAL.,License,Renewal No. - <br /> Serial No: i- v- <br /> "lGal:7Weights&Measures No: ' <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 34, 19 � ����� ` <br /> C No. of Vehicles Stored <br /> No. of Chemical Joilets Stored w <br /> 1 3, ❑ PERCOL^AT70N TEST R.S. or R.C.E.No. <br /> R.S.'or R.C.E.-Namea .. Test Date/Time <br /> y C J r - <br /> Test.f Location ;- <br /> 4.- ❑ SANITATION PERMIT <br /> Job Add r s/L C tion '+�J Addre s ~' <br /> Owner , ❑ PACKAGE PLANT <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD EEPAGEiPIT ❑ OTHER <br /> El PERMANENT ❑ TEMPORARY ❑ NEW EPAIR <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 t <br /> Type Construction <br /> i r.Disposal-Site v= <br /> No.of Units I Equipment Storage/Cleaning Location(s) <br /> t <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> Operator Name <br /> y <br /> Plant Location t <br /> - No. Units Served <br /> Plant Capacity ' <br /> 7. ('7 LAUNDRY For July 1,-June 30, 19 <br /> SIZE: <br /> ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,�000 Sq. Ft. r '' <br /> F-w-......., - �. . � <br /> ❑ DRY.CLEANING,Chemicais.Used/Amount/Mo. <br /> i i Ilcation an that the work will be done in accordance with San Joaquin County <br /> I <br /> hereby Ce, I have prepared this'�app <br /> ordinances*state lave d ule an�},{' regulation pof the S Joaquin .ocaI Health District. <br /> APPLICANT'S SIGNATORq <br /> x i <br /> FOR DEPARTMENT USE ONLY t <br /> REMIT <br /> Fee IS DUE'.❑ ANNUALLY ❑ PER UNIT _ ❑iPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 1 y <br /> fBILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE - +REMITTED AMOUNT 0. <br /> FEE � . <br /> LESS' ee 5 <br /> PRORATION S <br /> r PLUS ° <br /> PENALTY _ <br /> e 'I OTHER <br /> t <br /> OTHER i ►' <br /> - � 4ssuance Date fled Delivered <br /> t r D to receipt No. Permit No. . <br /> I reeeived�6y � 1601 E.HA2ELTON AY ., ox 2009 . STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES To: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> 1 <br />