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Applicatio s Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application, <br /> 30. APPLICATION <br /> 3p,N) (For.Non-Transferable;`Revocable,`and Suspendable) SEPTAGE <br /> f ENVIRONMENTAL HEALTH PERMIT f <br /> �I LIQUID WASTE <br /> Applica ion is herby made to car o busine n the j r fictional area of thearl,Jg6quint LOa�1 afth District <br /> OF <br /> Business Name (DBA} G (_ ddress <br /> z Owner _ <br /> Q -- ��-- -Address - - <br /> Firm Partners, Addresses and Tel ne Numbers ` <br /> IL Business Telephone No. (0 Emergency Telephone No. `• <br /> Contractor Licence No. -- <br /> L Applicants _Title <br /> ate <br /> Please check Appli ac ble Category(1-7) and Fill In the Required Information <br /> q M.> <br /> . • 1. ❑ •PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) � - <br /> For July 1,- June 30, 19 t- - "_-Disposal Sites _ p <br /> Description(Make/Yr., Color) ]� <br /> Serial No. CAL. License No. -- = r` ' f <br /> License Renewal No. <br /> Capacity.' -- ,-_ y. - r CAL" Lic.�rG-al:, 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 I <br /> R.S. or R C.E. Name R.S. or R.C.E. No. --� r <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERIJUT <br /> Job Address/L -cation J ��. pp <br /> L f <br /> Lb <br /> Owner 1 Address_- `� <br /> ❑ SEPTIC TANK 11CESSPOOL p EACHING FIELD_ SEEPAGE PIT, 11❑ PACKAGE PLANT j <br /> 11PERMANENT ❑ TEMPORARY EWEPAIR- ❑ OTHER 1 <br /> 5. ❑ CHEMICAL TOILETS For July 1, -Jude 30, 19 <br /> Type Construction Disposal Site <br /> No:of Units Equipment Storage/Cleaning Location(s) i d <br /> 6.'0,jPACKAGE TREATMENT PLANT For July 1, -June 30, 19 i !^ <br /> OperatorName <br /> Where Certified <br /> Plant Location ! <br /> Plant Capacity No. Units Served # <br /> 7, 11 LAUNDRY For July 1, -June 30, 19 <br /> SIZE: �❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. 1 <br /> ❑.DRY CLEANING, Chemicals Used/Amount/Mo. # <br /> ,firme ownerorficensedagent's slgngtiarncsrti#is <br /> -.ib suchITunner as Za UecWtli :a�"!certifylii?rq i irn.'?h,eperfor.masceoft_resterk.farwN0this ermitisissued,Ishallnotem to anYRQj <br /> rsnn�, v ,Cma ; com eaavisn; <br /> � contractor's hi' or aub-contra ting s€l�r�t errt'si;cs the Mn. ' ;i;?y StiaZ in the performance of the work for which this permit is issued,l shall <br /> •-empioy persons s jec kman's comps nsaZiun of California." I I' <br /> t I hereby certify that I In r re thls`•a licati and t a the w k will be done iii accordance with San Joaquin County <br /> ordinances, s ws, an rulgulati s of e In o quin al Ith District. <br /> APPLICANT'S SIGNATURE X <br /> -FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH` , ❑ January 1 & ce, January 31 <br /> ❑ July 1 &Received By July€31 <br /> - BILLING REMITTANCE REMi <br /> BASE EXPLANATION IT <br /> DATE AMOUNT DUE CHECKED <br /> t --DATE E TTED � - <br /> FEL w AMOUNT <br /> LESS <br /> PRORATION <br /> PLUS ' r' t <br /> PENALTY <br /> OTHER <br /> OTHER 6 i <br /> Re eived 15y Date I Receipt No: F Perm+t No.• - IgkuancDate Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1501 E.HAZELTON AVE-,P.O.Box 2009 STOCKTON,CA 95201 <br />