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—:— —� , <br /> Applications Will Be Processed When Submitted Properly Comple eBe <br /> tAPPLICATION <br /> (For Nor+-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL IID WASTE <br /> TH PERMIT <br /> Ilcation is herem to carryo busines in the jurisdictional area of the San oa Lim L�i Health District <br /> APP ` Address,i <br /> Y C <br /> Business Name (DBA) dress <br /> z Ownertf <br /> a <br /> Firm Partners, Addresses and Telephone INu {ers Emergency Telephone No. <br /> aBusiness Telephone No.— -7u <br /> Contractor Licence No. Title. -r+t� Date <br /> Applicants Name (Print) VL ' <br /> Please check Applicable Category (1-7) and Fill in the Required Information l <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, <br /> June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) GAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Gal.,Weights &Measures No. <br /> Capacity <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 V Test Date/Time <br /> Test LL tion t <br /> 4. LJ Si���M���ddress <br /> TION PERMIJob Ada Owner LEACHNLD GKSEEPAGE PIT 13 PACKAGE PLANT z <br /> ❑ SEPTIC TANK ❑ CESSPOOL OIREPAIR ❑ OTHER <br /> 11 PERMANENT <br /> [1 TEMPORARY 11 NEW <br /> 5. ❑ CHEMICAL_TOILETS For July 1, -June 30, 19 I <br /> Disposal Site <br /> Type Construction <br /> Equipment Storage/Cleaning Location(s) <br /> No. of Units � <br /> g, ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 Where Certified <br /> r <br /> Operator Name <br /> ( Plant Location -No, Units Served <br /> f Plant Capacity <br /> 7. ❑ LAUNDRY For July 1, -June 30.19 <br /> More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 5q. Ft., <br /> ,I ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> —2) <br /> klic ion and that the work will be done in accordance with San Joaquin County <br /> I hereby certify that I have pre nd this app <br /> I. <br /> r ulation of he an Joaquin Local Health District. <br /> ordinances, state laws, an and <br /> APPLICANT'S SIGNATURE X <br /> k - . <br /> k FOR DEPARTMENT USE ONLY r <br /> ❑ January 1 &Received By January 31-_-' ❑ July 1 &Received By July 3 <br /> M REMIT <br /> L Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EAG REMITTANCE AMOUNT DUE, ' CHECKED I� <br /> BILLING REMITTED <br /> BASE EXPLANATION DATE DATE <br /> s <br /> FEE _ <br /> l LESS <br /> PRORATION <br /> 4 <br /> . PLUS <br /> PENALTY. <br /> �•. OTHER <br /> OTHER ` <br /> `I tl S_ 3 � Mailed Delivered <br /> Permit No. Ssu ce Date CA 95201 <br /> Date- Receipt No. 1601 F.HAXELTON AVE.,P.O.Box 2009 STOCKTON, <br /> Received by <br /> + APPLICANT—RETURN ALL COPIES TO'.--ENVIRONMENTAL HEALTH PERMIT/SERVICES Gam ' <br />