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Applications Will Be Processed When Submitted ProperlyCompleted. Be sureTo Sign IneApplicauon. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ,?:-700 c,,) f-ED�''E—r��' � LIQUID WASTE OD ( ^ 2—( P 7 <br /> Applicati n is he;eb�y mad o carryon bu Ines 'n t juri dictional area of t a�Joaq Local Health D'st 'cl ��l <br /> rn Busines ame (DBA) Address <br /> z Owner Address <br /> 1 <br /> J Firm Partners, Addresses and Telephone NuKbers <br /> IL Business Telephone No. Emergency Telephone No. i <br /> Contractor Licence N <br /> Applicants Name (Print) Title Date <br /> Please check Applicabl ategory (1-7) and Fill in the Required ormation <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, .June 30, 19 Disposal Sites <br /> Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. Licc nse Renewal No. <br /> Capacity Gal., 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 <br /> R.S. or R.C.E. Name R.S. or R.C.E. No.. <br /> Test�LocTest Date/Time <br /> 4. [1"SANITATION P lT _ A47 <br /> JO b Adar /Location 'z <br /> Address <br /> Ow ll <br /> PTIC NK ❑ CESSPO L ,., LL ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT N <br /> u�PERMANENT ❑ TEMPORARY 'NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site SV <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <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 application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, a rules and r ula ' ns of S Joaquin Local Healtfi District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY 1 <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By 4anuary 31 my 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ OUNT DUE CHECKED <br /> DATE DATE fl ITT AMOUNT <br /> FEE <br /> LESS <br /> PRORATION i <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit No. Is uanc Date' Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2909 STOCKTON,CA 55201 <br /> 1 <br />