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..... <br /> Applications Will Be Processed When Submitted ProperlyCompleted. , <br /> kI � 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 San Joaquin Local Health District <br /> N <br /> ,Donald Se� <br /> Ire-It h <br /> Business Name (DBA) Mtice Tank Service Address r <br /> z Owner T•R MCDonalCi Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> CL Business Telephone No. 931-0497 _ 1 <br /> a <br /> _J Contractor Licence No. 30817 Title Date <br /> LApplicants Name (Print) T• R- TITCDonald <br /> 1 7 and Fill In the Required Information <br /> Please check Applicable Category ( - ) �j <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) CAL. Liccnse Rerewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 I <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4. 11 SANITATION PERMIT � b .- <br />'� Job Address/ ation l <br /> Owner Address <br /> ❑ PACKAGE PLANT <br /> SEPTIC TANK CES POOL EACHING FIELD 13REPAR SEEPAGE PIT ❑ OTHER <br /> []'PERMANENT ❑ TEMPORARY NEW <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> I No, of Units Equipment Storage/Cleaning Location(s) <br /> 4. 6. ❑ PACKAGE TREATMENT PLANT F'r July 1,-June 30, 19 Where Certified <br /> I. Operator Name <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> !cation and the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have prepared this appl <br /> N ,�a�l- ulat f the S Jo uin Local Health District. <br /> ordinances, state laws <br /> —APPLICANT'S SIGNATURE X (f <br /> I FOR DEPARTMENT USE O Y <br /> I Fee Is Due: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH [3J u 1 8 Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> - I BILLING I CE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE TE REMITTED AMOUNT <br /> FEE -7 <br /> I LESS <br /> PRORATION <br /> PLUS <br /> I PENALTY <br /> OTHER <br /> F <br /> +OTHER <br /> F - ` <br /> i x l O— O <br /> I (� <br /> Received by Date <br /> Receipt No. Permit No. Issuance Date Mailed Delivered <br /> 1601 E.HAZELTON AVE.,P.O.Bax 2009 STOCKTON,CA 95 <br /> 201 <br /> i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES V <br />