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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 /> ENVIRONMENTAL HEALTH PERMIT SEPTAGE <br /> LIQUID WASTE <br /> Application is eby ma eta rry o busi ess in the:u is tional area of the San aquin Local Health Distric <br /> F Business Name (D Addr s OeA r 7 <br /> z Owner Address ��— <br /> a <br /> J Firm Partners, Addresses and Telephone Numbers <br /> CL a Business Telephone No. � $ .0 Emergency Telephone Na <br /> Contractor Licence No. Z <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 /> Description(Make/Yr., Color) <br /> Serial No. r 4 CAL. License No. CAL. License 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 /> 3. ❑ PERCOLATION TEST _ <br /> R.S. or R.C.E. Name '' R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location 5111-11 21 <br /> Owner 'may Address <br /> ❑ SEPTIC TANK 13C SSPOOL ETILEACHING FIELD ,._< PAGE PIT ❑ PACKAGE PLANT ,r <br /> 11 PERMANENT —E].TEMPORARY 11NEW I� REPAIR ❑ OTHER A <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units ; Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name I j - ` t Where Certified Q� <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/Ma. <br /> m <br /> k <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 ations of the S o in Local Health District. 74 <br /> APPLICANT'S SIGNATURE X (J <br /> FOR DEPARTMENT USELY <br /> Fee IS Due: 13ANNUALLY ElPER UNIT ❑ PER SITE ❑ EACH ❑ Janu Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITT $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> FEECS <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER <br /> iD Gt�t � � � <br /> Received by Date Receip o- Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />