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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION , <br /> (For Non-Transierable, Revocable,and Suspendable) SEPTAGE j <br /> `1 ENVIRONMENTAL HEALTH PERMIT <br /> i - <br /> �' LIQUID WASTE 6 <br /> Application is her y ade to car lau ' ess i t e jurisdictional area of the San Joaquirt.J_ocal e i ict f1 <br /> rnBusiness Name BA) Address- <br /> z Owner Address <br /> a <br /> M Firm Partners, Add esses and Telephone Numbers <br /> 4 Business Telephone No. 1��p/,�7T72Emergency Telephone No. <br /> Contractor Licence No.. <br /> 4L Applicants Name (Print) Title Date <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) <br /> Serial No. CAL. License No. CAL. License Renewal No. l <br /> Capacity Gal., Weights &Measures No. <br /> 7 <br /> Equipment Parking Address -4 <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 <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. { <br /> Test Location Test Date/Time <br /> 4. ❑ 'SANITATION PERMIT ,y <br /> Job Address/L cation <br /> Owner 0 Addre <br /> ❑ SEPTIC TAN ❑ CESSPOOL LEA ING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT i <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW NEPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 1 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 J <br /> 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 applica ' nd that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules regulation of the an Joaquin Local Health Di t. 1 <br /> APPLICANT'S SIGNATURE X <br /> i <br /> 1 <br /> FOR DEPARTMENT USE ONLY ; <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT XPER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 1 <br /> REMIT i <br /> BILLING REMITTANCE $ <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> [� AMOUNT <br /> FEE r �y <br /> LESS <br /> PRORATION <br /> - I <br /> PLUS <br /> PENALTY � ` <br /> OTHER <br /> I <br /> OTHER 5 <br /> Received'by -%—Date Receipt No. Permit No. Issuance Date Mailed 7De <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 F.HAZELTON-AYE.,P.O.Box 2049 STOC ON,CA 24t ,j <br />