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Applications Will Be Processed When Submitted Properiy Completed. Be SureTosign inewppnunuvu. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> businessthe jurisd'ctional area of the San Joaquin Local Health District <br /> Applicatio hereby made o carry on <br /> rn Business Na (DBA) �74 17 <br /> Adss <br /> z Owner Address �( e <br /> 4 <br /> Firm Partners, Addresses and Telephone Nu bers <br /> K Business Telephone No, 1 Emergency Telephone No. C <br /> -jContractor Licence No. "7�,0m� <br /> Applicants Name (Print) Title Date iQ <br /> Please check Appllcabli Category (1-7)and Fill in the Required Information T" <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. Licc Ise Renewal No. <br /> p - <br /> Capacity Gal.,Weights,& Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehlcles Stored <br /> ,.No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST ` <br /> OWNR.S. or R.G.E. Name R.S. or R.C.E. No. <br /> Test Location —Test Date/Time <br /> f <br /> 4. 11 SANITATION PERMIT F 17 j_ <br /> Job Address/Loc lion �LEAdHIN <br /> - <br /> r Address PTIC T K 0 CESSPOOL ❑ ELD EPAGE PIT ❑ PACKAGE PLANT <br /> L� PERMANENT ❑ TEMPORARY ❑ NEW L REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction 4.,'Disposal Site <br /> No. of Units Equipment Storage/Cleaning Ldcation(s) <br /> k&vv% <br /> 6. E] PACKAGE TREATMENT PLANT For Ju y'l, -June 30, 19A% <br /> Operator Name Where Certified <br /> Plant Location <br /> iPlant 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 and,regulations of the n Jeaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY ! <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER S1TE ❑ EAGH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 24- 79 <br /> Received by Date Receipt No. Permit NO. Issuance Date Mailed Delivered <br /> WS <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E. ELTON AVE.,P.O.Box 2009 STOCKTON,CA 952 1 <br /> - - - - /� <br />