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.� ... �„r..,.� <br /> Applications Will Be Processed When Submitted Properly Completed. Be Sure ToSignThe <br /> APPLICATION <br /> (Far Nan-Transferable;Revocable,and Suspendable) SEPTAGE <br /> • ENVIRONMENTAL HEALTH PERMIT <br /> LIWASTE <br /> °Application reb ade to c on sin in the jurisQUID dictional area of the San Joaquin Local�H Ith Distr�lc i <br /> jUIC Address 0� 742 <br /> Business Na ( BA) <br /> r g C Address <br /> z Owner <br /> 1 Firm Partners, Addresses and Telephone Numbers Emergency Telephone No. <br /> aBusiness Telephone No. . g y p <br /> Contractor Licence No. .3 <br /> Title _ Date <br /> Applicants Name (Print) TIMI <br /> 1-7 and Fill in the Re uired Information r '•_s` ; s <br /> Please check Applicable Category ( 1 q � <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal—Weights=&Measures-No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER,YARD <br /> For July 1T June 30, 19 ; <br /> No. of Vehicles Stored <br /> R No. of Chemical To Stored <br /> 3. ❑ PERCOLATION TEST ,•^i R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location <br /> 4�SANiTATION PERMITI <br /> �T <br /> Job Address ation �. _ <br /> Owner Address <br /> ' E ING FIELD A5-SEEPAGE PIT ❑ PACKAGE PLANT 4) <br /> ❑ SEPTIC TANK CESSPOOL �/��" ❑ OTHER <br /> ❑ PERMANENT TEMPORARY ❑ NEW. <br /> fdAIR <br /> 5. ❑ CHEMI .T <br /> CAL- OILETS For July 1,-June 30, 19 p7Syr 3 <br /> r Type Construction Disposal Site r <br /> * h� �: <br /> No. of Units Equipment Storage/Cleaning Location(sJ <br /> 6. ❑ PACK G TREATMENT PLANT For July 1,-June 30, 19 Where Certified <br /> I Operator Name <br /> Plant Lobation u <br /> Plant Capacity No. Units Served <br /> i 7❑ LAUNDRY For(July1, -June 30, 19 � <br /> SIZE: �❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> j ❑,DRY CLEANING,Chemicals Used/Amount/MO. ) <br /> ' at the work will be done in accordance with San Joaquin Count <br /> I herebyCe of that I have re this a heatlon and that <br /> ordinances,st to laws, and rp s d regul Tons of San Joaquin Local Health District 41 ,I l <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> - PER SITE ❑ EACH ❑ Januarl.1 &Received By January 31 , ❑ July 1 8,Received By July 31 <br /> Fee'�S,DU; 13NUALLY ❑ PER UNIT ❑ P REMIT <br /> BILLING ' REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION ��..rDATE �, DATE REMITTED AMOUNT <br /> FEE <br /> LESS yi <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Delivered <br /> Received by Date Receipt No. <br /> Permit No. i, I seance Date Mailed. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES- 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 9520 <br />