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Applications Will Be Processed When Submitted Properly Completed.Be SureToSignTheAppiwatlon. <br /> •-� APPLICATION <br /> (For Non-Transferable, Revocable,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> WASTE <br /> Applic--tion is her�tq�r u iness' theju is retro I area of th a o urn L c eal Di trict:. \ <br /> OF Business Name (DBA) _.�— Address 4 <br /> i Owner _ Address <br /> Firm Partners, Addresses and I ne umbers <br /> aEmergency Telephone No. <br /> a Business Telephone No. =:t <br /> a - <br /> ._J Contractor Licence No. ^ ' <br />+'�Applicants'N me (Print) r' Titre ate- <br /> Please checKApplicable Category (1-7)and Fill in the Required Information . . <br /> f <br /> 1.70 .PUMP.ER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For`July 1" 1i -_t June 30, 19? a _ - - Disposal Sites - <br /> Description(Make/Yr., Color) w C <br /> Serial No. CAL. License No. +w AL� License Renewal No. <br /> capacity """— Gal.-;Weights- -Meas6m. No.'. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD { <br /> For July 1, June 30, 19 r <br /> No. of Vehicles Stored 9 <br /> No. of Chemical Toilets Stored ` <br /> 3:-^0-PERCOLATION,TEST-»- .W .R- ri _. .- �_-,-� - rr =-- _ -_.. 7 <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> r <br /> Test Location <br /> J -Test-Date/Time. <br /> �`. �� .. .�fI ..r�! ._��- � 1: �-.� �.) �"f;�"�! • � _ � <br /> 4. ❑ SANITATION P T+ <br /> Job Address/Location Address <br /> Owner <br /> ❑ SEPTIC TANK 1:1 CESSPOOL LEACHING FIELD EEPAGE PIT ❑ PACKAGE PLANT 1 <br /> ❑ PERMANENT C3TEMPORARY NEWREPAIR 1:1 OTHER l <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> j. Disposal Site r <br /> Type Construction , <br /> No. of Units ¥' Equipment Storage/Cleaning Locations) <br /> 6. ❑-PACKAGE.TREATMENT_PLANT. 'For July 1, June 30, 19 _ � <br /> Where Certified . <br /> Operator-Name y +• 3 'sz J <br /> Plant Location' <br /> Plant Capacity f"� 4. Units Served <br />' <br /> 7. ❑ LAUNDRY For July 1, -June'.30. 19 - i <br /> SIZE: f❑ Less Than 1,000 Sq.-Ft-,-L ❑ More Than 1,000 Sq. Ft._ <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo.� I ` <br /> N meowrnerorlieansadagent'swgnaturecertifiesthefollowing:"IcerfifythatintheperformameoftheworktorWhictl"perniitisissued.Ishallnotemployanyperson <br /> in suGfi manner as to btlsoltle sti�jeCi to rrorkelan's carnpsnsatinn laws 4f CalrTornia" �ti ,� f I <br /> s Corttraot * hiring or sub•to"MWtft signature cetrifies the fallowing: '1 certify that fn the performance of t1`1 work for which this permit is issued.I shall <br /> 4 employ persons subject to wwkmarfs compsimtiontaws atcaiifornia" <br /> I hereb certify�t ave-prepared t application n hat.the-work-will.be done.in�accordance with San Joaquin County <br /> l l <br /> ordinan es, a laws, n les n rl gu ati of a Sa Joaq Locat Health District. <br /> A\- <br /> APPLICANT'S SIGNATURE 1 <br /> FOR DEPAhTMENT USE ONLY... <br /> t i <br /> t 'Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ Er+CH ❑ January 1 &Received By January 31 ❑ July 1 &Received M July 31 $ <br /> ` REM4T <br /> iBILLING� REMITTANCE $ AMOUNT DUE CHECKED f <br /> BASE EXPLANATION DATE I l .DATE REMITTED - AMOUNT !Jj <br /> ---------------- <br /> FEE ' <br /> LESS } ,i✓ l? ' ' <br /> P,ROF.tATION. <br /> w <br /> PLUS <br /> PENALTY, 1 <br /> i OTHER ` f Y y} �.{ ! <br /> OTHER A _„-r--• � s—•� _ �.,t. <br /> ��-J,.- _�...�..,.(�-a- �-'-•---;� ���-�--' -------ISS�f .'�..s.:.�._.-.. .�..,.--..,.__...- __..�._�.�� <br /> .� <br /> G.- Issuance Date Mailed Delivered <br /> Received by Dat Receipl No. Permit No. t. <br /> g• ? APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HFALT14 PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,GA 95201 <br />