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of SA, <br /> v <br /> *0 <br /> Countywide Services Agency ` <br /> Bradley J. Hudson, County Executive <br /> Environmental Management o Ann Edwards, Chief Deputy County Executive <br /> Department Val F. Siebal, Department Director <br /> CA 4FOxN P <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 to —/0 - / RECEIPT# <br /> DATE PAID <br /> AMOUNT $ ( O Q <br /> NEW RENEWAL <br /> FIRM NAME OR DBA S2/�aDa� (7onta/r2 �P ( c f�jLc <br /> MAILING ADDRESS 17 c! I S E _ ( �1 Oc <br /> BUSINESS SITE ADDRESS SQ r-LF <br /> OWNERS(Partners, etcJ _[JAI��/ <br /> BUSINESS PHONE EMERGENCY PHONE CC&) V/7- -79S-(o <br /> VEHICLE USED <br /> Make and Model License Number Tank Capacity <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 /> 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 />