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Applications Will Be Processed When Submitted properly Corriplale(i Be Sure To Sign I tie APPIX111w, <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) SEPTAGE <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />Application ij d t airy on b sinthaj riscif'oponal area of the Joaq Local Health DinrjctZ <br />rpa( a o "Yon 0 UA <br />Business Na I,018A) Address <br />. . . ........ . <br />Address <br />z Owner <br />dW <br />0 Firm Partners, Addresses and Telephone Nta M 4 <br />71 <br />k Business Telephone No. Emergency Telephone No, <br />Contractor Licence No. <br />Title <br />LApplicants Name'jPrint)._ _ <br />, J— <br />ploasecheck Applicable Cat"ory (1-1) and Fill In the Required IntOrMaliOn <br />1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />Dispo"I sim <br />F,OrJuly l.—.r. . ... ... ... <br />Description (Make/yr, Color) . .............. . ...... <br />Serial NO.A CAL. License No, CAL, LZRenewal <7 <br />". <br />Capscity Gall Weights & Measures No, .......... <br />Equipment Parking Address --------- — -------- <br />2. 0 PUMPER YARD <br />For July 1 June 30, 19 <br />W, of Vehicles Stored - — ___-- <br />No. of Chemical Toilets Stored <br />3. 13 pEi4,CoLATioN TEST <br />R,S. or A.C.E. Name . . ..... ..... R.S. or R.C,E. No. __ . . ...... . . . . . ..... . ..... <br />. .............. <br />Test Lp� Test Date/Time ............... — - - — ------____ <br />4. 13 SANITATION PERMIT07, <br />Job Address) peation 57 7% A . ......... <br />LIA ... ........ :)Idx I . ........... LW�' <br />Owner . ...... 1­11[��' i:: __ <br />0 SEPTIC TANK CESSPOOL ILEAC 9#? FiEi D <br />SEEPAGE PIT 0 PACKAGE PLANT <br />0 PERMANENT TEMPORARY 0 NEW @-j—'EIR 0 OTHER EPA <br />0 CHEMICAL TOILETS For Juty1!-June 30,I9---4... <br />)e Construction Disposal A. Site . .. ........ . ........ <br />,vo. of Units Equipment StoragelCleaning Location(s) . ...... <br />6. 0 PACKAGE TREATMENT PLANT <br />For July 1, -June 3 19 <br />1, 6, . ...... Whom Certified <br />Uperator Name <br />Plant Location <br />Plant Capacity . . ......... <br />No, Units Served... <br />7. LAUNDRY For July 1, - Jur* 30, <br />SIZE: 13 Less Than 1,000 Sq, Ft,, 0 More Than 1,000 Sq. Ft <br />11 <br />0 DRY CLEANING, Chemicals Used/Amount/Mo. <br />1 hereby Certify that I have prepared this application and that the work will be d ' one in accordance with San . Joaquin I County <br />ordinances., state laws, and as and regulationsof the San Joaquin Local Health District. <br />APPLICANT'S SIGNATURE X . . ......... . . . ..... <br />FOR DEPARTMENT USE ONLY <br />12— is Due: 0 ANNU." Y 171 rf H irwT Et f -Em aiTF 0 EACH 13 January 1 & Aacaiv6d By iunuay 31 0 1.1y I & r'ievalv't'd By Juiv 31 <br />APPLICANT—ARTURN A" ODOM 16� <br />...... . ... <br />A No Permil Nostu6ficeDaa 6 i"d Del <br />MWIRONMENTAL HEALTH PIMMITt""ICES 9. HAZELTON AVIE., P.O. OW 2W9 STO <br />J3 A4"Ip 10/ 1/ <br />CA <br />BASE <br />WS <br />p EXPLANATION <br />all I ti <br />DATE <br />REM t IANCE <br />DATE <br />$ <br />ft -WITTED <br />ANIOUNTOUf <br />IREMIT <br />CHECKED <br />AMOUNT <br />S <br />PAC-44ATION <br />. .... . ..... <br />PLUS <br />PENALTY <br />OTHER <br />0T)-4FR <br />. .... . <br />. .... . I <br />APPLICANT—ARTURN A" ODOM 16� <br />...... . ... <br />A No Permil Nostu6ficeDaa 6 i"d Del <br />MWIRONMENTAL HEALTH PIMMITt""ICES 9. HAZELTON AVIE., P.O. OW 2W9 STO <br />J3 A4"Ip 10/ 1/ <br />CA <br />