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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> ( APPLICATION <br /> f , Eel_k� � (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> Z' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> yBusiness Name (DBA) / [ Address <br /> a Owner 6'J'%4 J- (�,!A%TP/C'y Address ?<1.19C?U 7J ki SC�v✓ atQ <br /> j Firm Partners, Addresses and Telephone Numbers r34- <br /> aBusiness Telephone No. Emergency Telephone No. - <br /> Contractor Licence No. el <br /> L Applicants Name (Print) K Title Date L <br /> Please check Applicable Category (1-7)and Fill in the Requir d 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 Gal., Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> l <br /> For July 1, June 30, 19 <br /> No. of Vehicles Storedv <br /> No. of Chemical Toilets Stored /N <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Testi ation Test Date/Time <br /> 4. CJ SANITATION PERMIT <br /> Job Address/Location ef '4 ® eel(7 rat- o <br /> Owner w Address <br /> M SEPTIC TANK ❑ CESSPOOL ❑�, LACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> PERMANENT 1:1 T1 L+T `N'�EW ❑ REPAIR ❑-'OTHER a0 X;k S %t✓ /j�•0 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site w <br /> No. of Units Equipme t Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <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. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this ication and the rk will be done in accordance with San Joaquin County <br /> ordinances, state la ules and re ions of the oa ocal Health District. <br /> APPLICANT'S SIGNATURE X <br /> Rw FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 11 ANNUALLY ❑ PER UNIT yl PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE y� <br /> LESS <br /> PRORATIONJai <br /> PLUS V NM <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Osr3.3 e� <br /> Received by Date I Receipt No. Permit No. Issuance Date Mailedelivere <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTONAVE.,P.O.Box 2009 STOCK ON,CA 95 0 <br />