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Applications Will Be Processed When Submitted Properly Completed- BeSure IoWgn IncnN�irr.aa.� <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i reby made to ca n bust ess in the jurisdictional area of th n Jo quin cal ealth Disth <br /> 1(2 / Address <br /> N Business Name(DBA) J �V <br /> aOwner Address 2 <br /> J Firm Partners, Addresses and Tele one Numb rs <br /> CL Business Telephone No. — `s c, Emergency Telephone No. <br /> Contractor Licence NO. �' - - tel Date <br /> L//Applicants Name (Print) 1, -, Title a oZj <br /> Please check Applicable Category (1-7)and Fill in 11h Required�lntormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l <br /> For July 1, June 30, 19 -T Disposal Sites - - <br /> Description(Make/Yr., Color) _ _ - <br /> CAL. License No. CAL.License Renewal No. <br /> Serial No-- ' <br /> Capacity Gal.,Weights &Measures No. <br /> Parking Address - <br /> 2_ ❑ PUMPER YARD <br /> For July 1, June 30, 19 r <br /> No. of Vehicles Stored r <br /> No. of Chemical Toilets Stored <br /> 3_ ❑ PERCOLATION TEST R.S.or R.C.E.No. t <br /> R.S.or R.C.E. Name - - <br /> Test'Location Test Date/Time , <br /> 4.; ❑ SANITATION PERMIT C-� <br /> ` Job Addre /Location " <br /> Owner Address <br /> ❑ SEPTIC TANK EI CESSPOOL ;&LEACHING FIELD F-1SEEPAGEPIT 4 ❑ PACKAGE PLANT <br /> } > ❑BOTHER <br /> El PERMANENT ❑ TEMPORARY 11 NEW 9REPA1Rw F G <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> e � <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> C 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 rav } Where Certified , <br /> Operator Name <br /> Plant Location __ i Aga•, <br /> Plant Capacity No. Units Served `. <br /> 7. ❑ LAUNDRY ' For July 1, -June 30, 19 ' 'y <br /> SIZE: ❑ Less Than 1,000 Sq. Ft,, C1,Mord Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo., r t `; <br /> _ r <br /> rsi.mz ovnerorrrcanwcrag rr.'s' •ratt<reccrtff,Z)z"to 46irin, r ^.{,•irr ;{rtrr, ;frrr? noes!f€iteeror4for v�i�ichthispermitisiss.led-1 shall slot elltptoy2nypersol <br /> dtl srr mariner a;to he�pMR„IFNi'X 'S man's alntpe 1s rtirn I:3CY5 c� !9:7S1i.+cc" " f f <br /> actor's htortg or pub cmmaciing 3#M <br /> t4le c0clif c.1 Des, fai€ovvfi;G: p,C: iiiy lhal intt�.pe fcr s ,^c,=.cf< s perk for ttihic,'z Ef is^eri it 1s i, ued.t shall <br /> �€tky persons suhjecl to tiverkmacfs ocw ,�sa 1pll kid Via€Galisw;n;a." <br /> I hereby certify that l have prep this applicatiL <br /> 0, a work w <br /> I ill be done in accordance with San Joaquin County <br /> ordinances, state laws, and rul a d reguions f e San Joa ; .ocal Health District. <br /> c <br /> APPLICANT'S SIGNATURE <br /> C' <br /> FOR DEPARTMENT USIt ONLY :� Y <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &ReceiveRdEByI July 31 <br /> BASE EXPLANATION BILLING REMITTANCE • $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE AOL <br /> K e t Yi✓` vC0LESS �"O GY•- -s <br /> PRORATION : w Y !LG OUrlf -411d e ^' <br /> PLUS <br /> PENALTY 1 i <br /> OTHER k�A./'� <br /> i <br /> OTHER .. _ 14 -'.-go <br /> -v ' <br /> I l l l 8 o-- <br /> Received b Dat Receipt No. Permit No Issuance Date Mailed Delivered <br /> APPLICANT--RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOGKTON,CSA 45201 <br /> C41-_2 C)- a C1 c h 1<6i-C�l )410 ro-z- I Irl-Pi e <br />