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Applications Will Be Processed When Submitted Properly Completed. BeSure Iosign Inexp}�ua .,,• <br /> APPLICATION <br /> f` f (For Non-Transferable;Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati hereby ade to car n busin in the jurisdictional area of the San Joaq i Loc e.alth istric <br /> Address , <br /> H Business Name (DBA) 1 ''6' f4 - <br /> Owner Address <br /> Firm Partners, Addresses a:)//I ho a�tNumbers ' <br /> 11 j �y 5� rggrgency TelZ�o.n..Pl: ve- <br /> aBusiness Telephone No. 4 <br /> Contractoi Licence No. Date <br /> Applicants Name (Print _ - Tit' , _. <br /> Please check Applicable Category (1.=7) and Fill in the Required~lnformation r s f-,cifv <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> Disposal Sites — <br /> For-July.i, _ -: - June-30;-1'9-w— _----."--� _' -�. .� t � ' <br /> Description(Make/Yr.,Color) "� .. <br /> CAL. License No. CAL. License Renewal NO:... <br /> j Serial No. " _ <br /> Capacity �* Gal.,•Weights & Measures <br /> I Equipment Parking Address w3 <br /> 2. CI PUMPER YARD t` . <br /> s <br /> For July 1, June 30, 19 Y ,� <br />} No. of Vehicles Stored _ `•� -_ <br /> ;No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION.TEST ;+,�, I 5 " <br /> � J'- <br /> R.S. or R.C.E. No. " <br /> R.S. or R.C.E. Name "¢ - <br /> Test Location 1 Test Date/Time <br /> 4. ❑ SANITATION PERMIT} <br /> 1 Job Addr ss/Coca ion• _ ' <br /> Address <br /> Owner Ll PLANT <br /> [],SEPTIC TANK ❑ CESSPOOL- C�-LEACHING FIELD Z EPAGE PIT F, r <br /> W ' � ` ❑ OTHER <br /> 8 RMANENT ❑ TEMPORARY p`I ��{ <br /> r 5. ❑ CHEMICAL TOILETS-For July l June-30,-19 <br /> Type Construction - Disposal Site ._ <br /> No. of Units I Equipment Storage/Cleaning Location(S) p- <br /> 6. ❑ PACKAGE.TREATMENT.'PLANT.. For, uly 1,.r June 30, 19 ' <br /> . -J- .... �,..— Where Certified <br /> Operator Name ," t t. } <br /> Plant Locationi A. <br /> No, Units Served <br /> Plant Capacity <br /> 7. ❑ LAUNDRY 1 For July.i, -June 30, 19--i— <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used mount/Mo. ell <br /> J <br /> �,v"sr�cc• � � . <br /> is application an work will be done in accordance with San Joaquin County <br /> hereby certify that ! have <br /> Ith District. <br /> ordinances, state laws ru regul n a in ocal _ <br /> APPLICANT'S SIG " <br /> 4 <br /> FOR DEPARTMENT USE ONLY <br /> v Be I5 Due: ❑ ANNUALLY PER UNIT PER SITE ❑ EACH - ❑ January i'&Received By January 31 ❑ July 1 &Received By my 31 <br /> EMIT <br /> BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> a <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS - <br /> PENALTY _ •!' <br /> OTHER <br /> OTHER <br /> --� _ v P <br /> U ! (J + , <br /> Date ,Receipt No.y Permit No. ssuanc Date Mailed Delivered <br /> Received by I <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES` - 1601 E.HAZELTON AVE.,P.O.Box 20U9 STOCKTON,CA 85201 <br />