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Applications Will Be Processed When Submitted Properly CompleteBe SureI <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> " ENVIRONMENTAL HEALTH PERMIT , <br /> LIQUID WASTE s <br /> is hereby m Qtoo car on business i „!ctionaAddressthe San Joaquin L <br /> Applicatlocal Health District <br /> Business Name (DBA) �A�dddress d� S <br /> aOwner <br /> Addresses and T + <br /> elephone Numbers <br /> Firm Partners, c <br /> Emergency Telephone No. <br />'i a Business Telephone No. 63 1 <br /> Contractor Licence No. Title Date <br /> a Ap licanis Name (Print) <br /> L_ ' ' Applicable Category (i-7) and Fill in the Required Information <br /> Please check App <br /> i i, ❑ FOR EACH VEHICLE) <br /> PUMPER VEHICLE PERMIT REGISTRATION ( <br /> 19 Disposal Sites <br /> For JuJune 30,ly 1, <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. : <br /> Serial No, <br /> Capacity Gat.,Weights &Measures No. <br /> ( <br /> I Equipment Parking-Address <br /> 2. ❑ PUMPER YfkRD r <br /> For July 111i June 30, 19 t <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 Test Date/Time <br /> f Test Location _ _.� 55,4Air� <br /> 4. W SANITAF16N PERMIT" pr! T l <br /> Job Address/Lobation40 f Address <br /> -Owner- ' � � ❑ PACKAGE PLANT i <br /> ❑15EPTIC TAN ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT a <br /> ❑ PERMANENT ❑ TEMPORARY <br /> ❑ NEW ❑ REPAIR -1 OTHER <br /> 1,-June 30, 19 <br /> 5. ❑ CHEMICAL,TOILETS For July Disposal Site <br /> Type Constructlon� <br /> I Equipment Storage/Cleaning Location(s) <br /> No. of Units f <br /> g. 11 PACKAGE TREAT PLANT For July 1, -June 30, Where Certified <br /> Operator Name <br /> i Plant Location No. Units Served - <br /> Plant Capacity <br /> ` 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: <br /> ❑ Less Than 1,000 Sq. Ft., '. =❑ More Than 1,000 Sq. Ft. <br /> - <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> � t <br /> t L.prepared i <br /> I hereby certify that I have preparedd re lulatpplicions of th and <br /> t Joaquin Local Heaill't; td District, <br /> in <br /> ccordance with San Joaquin County <br /> k ordinances, state laws, a es an 9 <br /> P 'A, � A <br /> or <br /> APPLICANT'S SIGNATUREX �j(_ <br /> FOR DEPARTMENT USE ONLY <br /> ❑ January 1 &Received By January 31 ❑ July 1'&Received By July 31 <br /> I REMIT <br /> PER SITE <br /> EACH: <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT $ AMOUNT DUES CHECKED <br /> LIN <br /> L T 1061L6 REMITTANCE AMOUNT <br /> BASE d EXPLANATION 4DATf'"F 4. DATE REMITTED <br /> i ,FEE <br /> LESS S <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER i <br /> OTHER ,--7� <br /> No, <br /> issuance D to Mailed DON red 2 a' <br /> Date Receipt <br /> - Permit No.-. 201 <br /> Received by - 1601 E.'RAZELTON AYE.,P.O.Box 2009 STO KTON, A 95 <br /> APPLICANT_RETURN ALL COPIES TO:' ENYIAONMENTAL HEALTR PEAMITISERVICES � � �,,,-� y <br />