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OF SA( <br /> ? {yp4 fr q�� <br /> p OO <br /> Countywide Services Agency Bradley J. Hudson, County Executive <br /> ° <br /> Environmental Management d Ann Edwards, Chief Deputy County Executive <br /> ,� <br /> Department Val F. Siebal, Department Director <br /> Cq C IFORW <br /> Environmental Compliance Division County of Sacramento <br /> Elise Rothschild, Chief <br /> SEPTIC TANK, CHEMICAL TOILET & <br /> GREASE TRAP CLEANER REGISTRATION APPLICATION FACILITY# <br /> PROG REC# <br /> PE 4270 <br /> DATE lo-/v /3 RECEIPT# 55 <br /> DATE PAID G Ito / 13 <br /> AMOUNT $ 3Q(•0 0 <br /> NEW RENEWAL <br /> FIRM NAME OR DBA <br /> MAILING ADDRESS '21-2 S$4 (174 { 04' . CJ j C 32 <br /> BUSINESS SITE ADDRESS SAekC <br /> OWNERS (Partners, etc.) (JAnP�C--7 a ( e <br /> BUSINESS PHONE (ZoQ -2 `{S`-�7a�J EMERGENCY PHONE (TO q17- --79,5 fe <br /> VEHICLE USED <br /> Make and Model License Number Tank Capacity <br /> Z/.(.(7 7c/ S©o <br /> CHECK USAGE OF VEHICLE Chemical Toilets ✓ Septic Tanks ✓ Grease Traps <br /> I certify that the above information is true and correct, and that the proposed work will be done to conform to all <br /> conditions, orders and directions pursuant to Section 117400-117450 inclusive, California Health and Safety Code, <br /> and Sacramento County Code, Chapter 6.32. <br /> Signed: Date: <br /> Owner or Authorized Representative <br /> COMPLETE THE FOLLOWING CERTIFICATION ONLY IF YOU DO NOT INTEND TO OPERATE IN <br /> SACRAMENTO COUNTY DURING THE ENSUING YEAR: <br /> I hereby certify that the above firm or DBA does not intend to operate in Sacramento County during the calendar <br /> year subject to this application. <br /> Signed: Date: <br /> Owner or Authorized Representative <br /> 10590 Armstrong Avenue,Suite A . Mather,California 95655 . phone(916)875-8400 . fax(916)875-8513 . www.saccounty.net <br />