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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> r APPLICATION <br /> i (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> I � ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> Business Name (DBA)T_,-A r'4R- _1S 4 iS Address <br /> I z Owner Address <br /> c <br /> J Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. 4&6—176,077 Emergency Telephone No. <br /> d Contractor Licence No. - <br /> L Applicants Name (Print) 0 Title Date �`�r 7 <br /> i 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. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address (/► <br /> 2. ❑ PUMPER YARD p� <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. JQ SANITATION PERMIT <br /> Job Address/Location 5- e1 <br /> . er rR0 _P-T ; Address 's? <br /> Zt <br /> zWEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> )<PERMANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER _ <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 /> f 6. ❑ PACKAGE TREATMENT PLANT For July;1, -June 30, 19 <br /> t Operator Name Where Certified <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/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, and rules and regulations of the W Joaquin Local Health Dis t. <br /> APPLICANT'S SIGNATURE X <br /> , r <br /> gj <br /> FOR DEPART I ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT h PER SITE E H ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASF EXPLANATION BILLI REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE REMITTED AMOUNT <br /> r <br /> FEE <br /> LESS „ <br /> PRORATION _ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No, Issuance Date Mailed e ry ed <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCkTON,C 95201 <br />