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Applications Will Be Processed When Submitted Properly Completed. BeSureTO sign inePtppuc:arwri. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT Ar <br /> LIQUID WASTE <br /> Applicata s herebx m de toa on business in th�jurisdictional area of the S/n Joaquin focal Health Diatri�c�t <br /> H Business Nam�,,(DBA)_ <br /> ir�lr��)[� ,I �(_ flo& Address - O �1i C-0" 1`l <br /> a Owner f C'ARGNe i! Address <br /> DR Firm Partners, Addresses and Telephone Numbers <br /> 8� - �553tf <br /> a Business Telephone No. Emergency Telephone No. <br /> `13 9i <br /> Contractor Licence No. Date <br /> L Applicants Name (Print) Title } <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) CAL. Lic-,se Renewal No. <br /> Serial No. CAL. License No. <br /> Capacity Gal.,Weights & Measures No. <br /> s <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 /> R.S. or R.C.E. Name <br /> Test Date/ <br /> Test Location Time <br /> 4. ❑ SANITATION PERMIT�.UOvss �� <br /> Job Address/Location <br /> Owner W 1 NrJ1 e2 Address - <br /> 19 SEPTIC TANK ❑ CESSPOOL RL LEACHING FIELD ❑ SEEPAGE PIT . ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 ��00 't 7Sc 7'A.- �� r10 /rAc/1 <br /> Type Construction Disposal Site S <br /> No. of Units <br /> Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Served s <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. <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, les and regulations of the n Joaquin Local Health District. 1 # <br /> Ir /Z <br /> APPLICANT'S SIGNATURE X <br /> 0 II <br /> t FOR DEPARTMENT USE ONLY <br /> Fee Is Due:.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July i &ReceiveRdEB1ylj my 31 <br /> 1 BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE pDATE REMITTED AMOUNT <br /> �00 <br /> FEE <br /> LESS �x <br /> a PRORATION14 <br /> 1 <br /> PLUS r fj <br /> PENALTY Y <br /> OTHER <br /> .OTHER <br /> Receipt No Permit.No. Issuanc Date Mailed Deliver <br /> Received by Dat ed <br /> ENVIRONMENTAL TO:'F ENYIRONENTAL HEALTH PERMITlSERVICES .1801 E.HAZEL? YE.;P.O.Bax 2009 STOCKTON,CA 95201 <br /> APPLICANT—RETURN ALL COP <br />