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Applications Will Be Processed When Submitted Properly Completed. Be SureTosign ineAppncau0n. <br /> APPLICATION <br /> *y (For Non-Transferable, Revocable,and Suspendable) f SEPTAGE ; <br /> ENVIRONMENTAL HEALTH PERMIT <br /> _ LIQUID WASTE <br /> Application is hereby madeo-trar on b ness-in the jurisdictional area oft San J aquin Local Health Di r f ' <br /> Business Nam (DBA) �! er Address = — y ti a <br /> I- - Address ! <br /> za Owner T. <br /> Firm Partners, Addresses and Telephon Numbers <br /> IL <br /> Business Telephone No. Emergency Telephone No. <br /> ` . <br /> .J Contractor Licence No. Date <br /> L Applicants Name (Print) Title + <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 i <br /> Description(Mhke/Yr., Color) 1 <br /> CAL. License Renewal No, <br /> Serial No. CAL. License No. <br /> Capacity — § Gal Ft Weights,&Measures No. d <br /> Equipment Park�in'g Address <br /> 2. ❑ PUMPERARD s _ <br /> For July 1 !:_'June 30, 19 <br /> , ( <br /> No.of Vehicles Cored <br /> No. of Chemical Toilets Stored t �t <br /> 3. ❑ PERCOLATION TEST 1. <br /> R.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Date/Time <br /> TesrLtion <br /> q. NITATION PERM � � � ( ,,0 n &�, vl U) <br /> Job Address/Location `7 <br /> O�w er Address. Q l <br /> t`d 51=PTIC TANK ❑ CESSPOOL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT Imo' <br /> 1:1PERMANENT El TEMPORARY ' NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS. For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> -r� <br /> No. of Units Equipment Storage/Gleaning Locatlan(s)• <br /> _. s,r <br /> I 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> h Plant Location r <br /> Plant Capacity No. Units Served <br /> - y <br /> t 7.. ❑ LAUNDRY _For JuIX'i'-June 30, 119 <br /> SIZE: ❑.Less Than 1,000 Sq. Ft., ❑ More Than-1,000 Sq. Ft. <br /> ❑ DRY CLEANING,,Chemicals Used/Amount/Mo. <br /> fir-.. <br /> I hereby certify that I have p1repare-d this app ati and that the,work will- <br /> ordinances, state laws, and r e regu ns ;e San�Joaquin Local Health Distrie <br /> APPLICANT'S SIGNATURE X <br /> - i <br /> r <br /> * FOR DEPARTMENT USE ONLY <br /> I Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ` i "� REMIT . <br /> I RASE EXPLANATION BILbNG REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> -FEE - <br /> LESS - -- --,- - . - <br /> ' PRORATION <br /> I; PLUS i <br /> PENALTY , <br /> OTHER -.: <br /> } OTHER <br /> 4 <br /> seance +, <br /> �- Received by Dare - 'Receipt No. - Permit No pate Mailed Delivered , <br /> k R APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P;O.Bay 2009 STOCKTON,Cb 95201 <br />