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'zo Applications Will Be Processed When Submitted ProperlyCompletea. tiesure ioalgn IIlC„rN .a.... <br /> APPLICATION . <br /> J (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT I <br /> LIQUID WASTE ��E� <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> mBusiness Name (DBA) Address <br /> I Owner G Address <br /> ..� �O <br /> d <br /> Firm Partners, Addresses and Tel hone Numbers <br /> a Emergency Telephone No. <br /> a. Business Telephone No. <br /> �Contractor Licence No. <br /> LApplicants Name (Print) O Title Q a.r,.I=a'_ - Date j <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity F Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2.`'❑ PUMPER YARD <br /> For July 1, I June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PER60LA710N TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. 0 SANITATION PERMIT <br /> I <br /> Job Address/Location 6 V <br /> O,w�r �772Address 9 ' <br /> SEPTIC TANK 11 CESSPOOL ❑ EACHING FIELD SEEP7K£ PIT 13 PACKAGE PLANT ' ,� � 4r <br /> ❑ PERMANENT ❑ TEMPORARY NEW REPAIR OTHER -. �f o - <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ea <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning LoCatiorl(s) <br /> r <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> - Where Certified <br /> t <br /> Operator Name ` <br /> Plant Location <br /> No. Units Served <br /> Plant Capacity <br /> P7. ❑ lsLAUNDRY 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 /> ti. <br /> Mame ownerorficensed ngent's "I rertifl:ilial f;1 the perinrmance `411 r F is r ' ' l em loy any per n <br /> in such manner as to becnlrc sul):OCi fc'.,crri^sa ,r. •Ili :.i::2 ii'':,i yY':3+ii f;Aifnl i1:It <br /> Contrar',�r'g hiring or „�:'r.1•cc.. r.Se2^.a,;i s:sr4:•"� c'' "^S 1ha3 €iVVA,-1(j; `I;cr,lt;�*that m th p .to- i i 'forrfv'a <br /> iC�1 i5lssue3,I shall e <br /> employ persons subject to Lvcri;n:a:i S L 1110ii�a`:luii IeL'r� i�371`GCi:iu.'' t <br /> V hereby certify that.•I have prepared this application and that the work'will be o e in orT1 , n C <br /> ordinances, state lay s, nd rules and reg latiohs of Yhe`SSt1 Joaquin Locai'Healt <br /> APPLICANT'S SIGNATURE <br /> FOR DElARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY El PER UNIT PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31�. <br /> -.I REMIT <br /> I r.$ILLING REMITTANCE $ <br /> BASE EXKANATION *' AMOUNT DUE. CHECKED.., <br /> DATE' DATE REMITTED AMOUNT <br /> FEE 5! <br /> s �� <br /> LESS ! <br /> PRORATION <br /> PLUS •� 1+�' \ - --•'• -- "-- <br /> PEN;hiTY (/ J <br /> f <br /> OTHER <br /> OTHER q <br /> ko 416 <br /> Received by Date Receipt No. Permit No, Iss ante ate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA TON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />