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f Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> f APPLICATION <br /> } (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is h by Made to cWy on Usines in the'uris icti nal area of theS Joaquin Local Health District <br /> Business Name (De } dress � ...� <br /> ! z Owner ddresss➢����"' <br /> a <br /> Firm Partners, Addresses and Telephone Numbers --- <br /> I $ Business Telephone No. �� ~._ t--- - Emergency Telephone No <br /> , a - <br /> Contractor Licence No. <br /> L 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 /> I Description(Make/Yr., Color) -- <br /> Serial No. - CAL. License No. _ CAL. Lice.se Renewal No. <br /> Capacity Gal., Weights &Measures No. - --� <br /> Equipment Parking Address --- <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored ---_- -- ---- <br /> No. of Chemical Toilets Stored - - -- - <br /> I 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name . -. - R.S. of R.C.E.No. <br /> Test Location _ Test Date!Time _ <br /> I 4. ❑ SANITATION PERMIT <br /> Job Address/Lo ion _ <br /> EEf OYw °r Address ❑ OTHER <br /> 8� TIC TANK 13 CESSPOOL HINGFIELD PACK E PLANT <br /> MNEW ❑ RE IRLPERMANENT ❑ TEPORARY <br /> _ <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> ype Construction Disposal SiteNo.of Units ..... ___ _ Equipment Storage/Cleaning Location(s) _-- <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name - Where Certified <br /> i 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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,and rules regulatio of Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X 0,4 -- - <br /> rbc FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY [3 PER UNIT La PER SITE ❑ EACH ❑ January 1 &Received.By January 31 ❑ .:uly 1 &Received By J,iy 31 <br /> - HEMI r <br /> ` BASE E%PLANAI ION BILLING REMITTANCE 5 AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FFF <br /> Y <br /> LESS <br /> PRORATION _ - <br /> PLUS <br /> PENALTY <br /> i OTHER <br /> [ OTHER <br /> C) <br /> Vit! <br /> Received by Date Receipt No. )it No. Issuance late Mailed Delivered - +s <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.BOX 20025TOCKTON,0201 — <br />