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Applications Will Be Processed:When Submitted Properly Completed. Be Sure To Sign The Application. p T
<br /> ,l ° 1, APPLICATION
<br /> ' (For Non-Transferable,Revocable, and Suspendable) SEPTAGE
<br /> •-ENVIRONMENTAL HEALTH PERMIT
<br /> ` LIQUID WASTE
<br /> Application is hereby made to carg on business in the jurisdictional area of the San Joaquin Local Health District
<br /> ti Business Name (DBA) � � SQ/1��.�rMilsX Address
<br /> .
<br /> z Owner
<br /> a .1 Address
<br /> Firm Partners, Addresses and Telephone Numbers
<br /> aBusiness Telephone No, d Emergency Telephone No,
<br /> Contractor Licence No. L 14-M
<br /> L Applicants Name (Print) -Title AA ATEI Q Date
<br /> Please check Applicable Category (1-7)and Al in the Required Information
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)
<br /> For July 1, -L-June 30, 19 Disposal"Sites= '
<br /> Description(Make/Yr., Color)
<br /> Serial Na. e - CAL. License No. CAL. License Renewal No. f
<br /> Capacity ) _ GaLiWeights & Measures No.
<br /> Equipment Parking Address !.,4 r� l � A t
<br /> 2. ❑ PUMPER YARD" •r .,-
<br /> For July 1, _4 June 30, 19 r"
<br /> No; of Vehicles Stored
<br /> ,No. of Chemical'Toilet§`Stored
<br /> 3. ❑ PERCO'LATION*,TEST
<br /> R.S. or R.C.E. Name R.S. or R.C.E. No.
<br /> Test Locati n
<br /> ,.,., Test Date/Time
<br /> 4. IlYANITATTON PERMIT
<br /> Job Address/Location0 C T,
<br /> Owner Address
<br /> ❑ SEPTIC TANK ❑ CESSPOOL q• R LEACHING"FIELD O SEEPAGE PIT ❑ PACKAGE PLANT#
<br /> 9-TTRAAANENT ❑ TEMPORARY ❑ NEW, 3-11'EPAIR 8"6-HER J6_JSa :S I�
<br /> 5. ❑#,CHEMICAL TOILETS For July 1,-June 30, 19 -tom-
<br /> Type
<br /> Disposal Site ti CN
<br /> No. of Units ,= Equipment Storage/Cleaning Location(s) �=
<br /> 6. ❑PACKAGE TREA_TMENT'PLANT For July 1, -June 30, 19 A i N jr
<br /> Operator Name i - ��- '. '� •Where Certified
<br /> Plant locations - �r
<br /> Plant Capacity t No. Units Served
<br /> 7. ❑ LAUNDRY For July 1, -June 30.v19 R
<br /> -SIZE: ❑ Less Than 1,000 5q. Ft., ❑ More Than 1,000 Sq. Ft.
<br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo.
<br /> # _
<br /> I hereby certify that I'h reparedtli& pplicatib d Aha he woLN will be done in accordance with San Joaquin County
<br /> ordinances, state laws r a Ion J quin L al Health District.
<br /> APPLICANT'S SIGNATURE �,0��
<br /> anl��
<br /> w FOR DEPARTMENT USE ONLY , *�
<br /> Fee Is Due: ❑ ANNUALLY �'""#'
<br /> ❑•PER UNIT,,,,, ❑ PER-SITE;`b ❑:EACH January I &,Received 8y-January,31 ❑ July A..&Received By July.33
<br /> BASE EXPLANATIONBILLING _� "REMITTANCE 4 °N", REMIT
<br /> }. # $. i DATE R �`OATE '`A REMITTED "" �y��MOUNT DUE CHECKED
<br /> AMOUNT
<br /> FEE
<br /> LESS
<br /> PRORATION
<br /> PLUS �;
<br /> PENALTY # 9 �f �3� q @i# �t .
<br /> tA- yy 'T� � J V t _ -
<br /> OTHER
<br /> OTHER ` „ 'y' =--•moo—r,w �.f: `�"' �' = t',,,,,.,".: {
<br /> Ion
<br /> Received by Date Receipt.No- ,�. Permit No.-" --,, ' ssu n ate- Mailed Delivered
<br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL'•HEALTH PERMIT/SERVIC£3° •� '�'16011E.HAZE -? v)=,,.?.O.Boa 2009 STOCKTON,CA 95201
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