Laserfiche WebLink
Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i ergby m e arty on usine s in the juri fictional area of the S o qu Local Health District <br /> y Business Name (DBA Address <br /> � � �!� <br /> z Owner Address <br /> 9 <br /> Firm Partners, Addresses and Tele hone Numbers <br /> a Business Telephone No. f Emergency Telephone No. <br /> a ^� <br /> Contractor Licence No. <br /> Applicants Name (Print) $ Title Date <br /> pleasF check A�pli ble Cate ory (1-7)and Fill in the Required In rmaHon <br /> 1. ❑ r�khh ►EIt� tMMIT REGISTRATION (FOR EACH VEHICLE) -- <br /> `Ftf % °" -J,;�q 30, 19 Disposal Sites <br /> `Dbjiar*io.p(Vake/Yr„.Col jr� <br /> Seria�No. -t�_ CAL. License No. CAL. License Renewal No. <br /> Capa 11 ' a1., elg is 8 Measures No. <br /> �br�Pa�icing�A�[ir�.�,s <br /> 2. aPUMPEA YARD.%,-, t <br /> For'July ,kr <br /> No. of Vee icleS•Stx�red. v ` `-'• n � ' <br /> No"of Cher;iioal Tt,Its Stored <br /> 3. ❑�PEACOLATION:T-,E ,4,� <br /> • s <br /> R.S. or E. Name R.S.or R.C_E. No. <br /> r <br /> Test cation ;. Test Date/Tiri1 '� •?�r►. �s�i$ <br /> 4. SANITATION PERMIT ' <br /> Job Address/Location e <br /> Ow r IFII <br /> ress <br /> ❑ PACK E PLANT <br /> Orr <br /> TANK ❑ CESSPO L LE HISEEPPili '".•� _ <br /> PERMANENT ❑ TEMPORARY ❑ NEW PAIR ❑ OTHE <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site _ <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> r <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. .c „ <br /> DRY CLEANING, Chemicals Used/Amount/Mo. -' <br /> : r <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rut and re ulations of he San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY d_t- <br /> Fee IS DUB: ❑ ANNUALLY PER UNIT ❑ PER SITE ❑ EACH 0 January 1 &Rec `ed,By Janu 31 July 1 &Received By July 31 <br /> ^i REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ / AMOUNT DUE CHECKED <br /> DATE DATE TE411AMOUNT <br /> FEE L <br /> LESS <br /> PRORATION / <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER t. _� OL V <br /> ./ <br /> r <br /> Received by Date Receipt No. Permit.Na. Iss ance DL e Q -Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AYE.,P.O.Bax 2009 STOCKTON,CA 95201 <br />