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Applications Will Be Processed When Submitted Properly Completed. Be Sure.To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable;Revocable, and Suspendable) <br /> ENVIRON :NTAL HEALTH PERMlT SEPTAGE <br /> kxj'-,�LIQUID WASTE,; <br /> Application Is her h <br /> pp y ade�carly,oli- [Hess In the jurisdictional area of the San Joaquin Local Health Dist 'ct <br /> y Business Name (DBA)_-. - e �i�rC� _ Address 1201` L <br /> aOwner It., Address <br /> Firm Partners, Addresses and Teleph ne um <br /> aBusiness Telephone No, Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) Title �. Date <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 Gal., Weights & Measures No. <br /> I Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 — •� f <br /> No. of.lfehfcles Stored r <br /> No. of 9,flemical'Toilets Stored <br /> 3. RCOLATION TEST <br /> R.S. or R.C.E. Name t R.S. or R.G.E. No. <br /> Test.Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT r <br /> Job Address/Location eQ 1C/1_9_ " JD N. <br /> Owner rr--,, EA�� Address <br /> 1`- EPTIC TANK ❑ CESSPOOL Q—CC;HIIVG FIEM-0-SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> 1 Type Construction i j Disposal Site t� <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLkNT 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 /> F 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 rules and re atio the SarLJoaquin Local Wealth District. ]� <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: C1 ANNUALLY Li PER UNIT r ❑ PER SITE ri ❑ EACH' ❑ January 1 &Received By January 31 ElJuly 1 &Received By July 31 y s <br /> REMIT <br /> BASF-- } EXPLANATION BILLING R9MITTANCE $ AMOUNT DUE CHECKED <br /> f t DATE DATE REMITTED AMOUNT 9 <br /> FEE <br /> LESS '* t ); <br /> PRORATION rawer:a <br /> PLUS <br /> PENALTY!' <br /> OTHER �i [, , <br /> OTHER <br /> Received by Date Receipt No Permit NO. 4suancEl Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 16D1 E.HAZELTON AVE.,P.O.Box 2009 STDCXTON,CA 95201 ,� <br />