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isa...,.. <br /> Applications Will Be Processed When SubAmPittPeL'rCaPAeTiONrly Pleted. Be Sure o <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br />' ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application' hereby ma to carryon business in the jurisdictional area of the Sago u Loc Health Dysl <br /> 8 Address <br /> F Business Name (DBA) Address43 d <br /> aOwner � � �� ' <br /> J Firm Partners, Addresses and Tele hone Numbers Emergency Telephone No. <br /> - !'2.C7 l 9 Y <br /> aBusiness Telephone No. - <br /> .J Contractor Licence No. Title Date <br /> L Applicants Name (Print) - <br /> uired Intormaiion <br /> Please check Applicable Category (1-7) and Fill in the ReqO <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> I <br /> For July 1, June 30. 19 Disposal Sites <br /> Description(Make/Yr.,Color) CAL. License No. CAL. License Renewal No. <br /> I Serial 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 R:S.or R.C.E. No. <br /> I R.S.or R.C.E. Name Test Date/Time <br /> r Test Lo n <br /> 4, U SANITATION PERMIT <br /> f <br /> Job Address/Loca ion 3 <br /> Address <br /> Owner ❑ PACKAGE P ANT <br /> ❑ S TIC TAN El CESSPOOL EACHING IELD SEEPAGE.PIT ❑ OTHER <br /> ❑ TEMPORARY ❑ NEW—. �-.� - -�❑-REP-AiR — »� <br /> ( PERMANENT - <br /> I & ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction <br /> Disposal Site <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> Operator Name <br /> r Plant Location No. Units Served <br /> Plant Capacity <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. r <br /> I hereby certify that I have prepared this ut. <br /> lapoli sats he and <br /> that the work n Joaquin Local ill be <br /> done <br /> i naccordance with San Joaquin County <br /> k ordinances, state laws, and s 9 �� <br /> APPLICANT'S SIGNATURE X <br /> 11 FOR DEPARTMENT USE.ONLY <br /> PER UNIT PER SITE EACH [3�January 1 &Received By January 31 July 1 &Received By July 31 <br /> Fee Is Due: ❑ ANNUALLY [:I REMIT <br /> BILLING REMITTANCE. $ AMOUNT DUE CHECKED <br /> EXPLANATION DATE DATE REMITTED AMOUNT <br /> I; BASE � v <br /> J <br /> FEE <br /> LESS, <br /> _. 4 <br /> T PRORATION <br /> PLUS n <br /> PENALTY fr <br /> OTHER <br /> J <br /> OTHER <br /> Mailed Delivere 7 <br /> Date ,.� Receipt No. <br /> Permit No. '- - Issuance pate <br /> Received by 41801 E.HAZELTON AVE.,'P.O:Box 2609- STOCK ON,CA 9 Ot <br /> APPLICANT-RETURN ALL COPIES T �ENVIRONMENTALHEALTH'PERMITISERVICES <br />