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,. Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. r <br /> w APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT —.2) <br /> LIQUID WASTE l ' <br /> Application is her y made to ar on business in the jurisdictional area of the San Joaquin Local Health District /} <br /> rr-- y —021CC.� <br /> OBusiness me (DBA)—,0 �"4w rY" Address <br /> a 2 Owner i `lL Address (f " /I/o ` <br /> 9 Firm Partners, Addresses and Telephone Numbers S >rtr �q O� <br /> aBusiness Telephone No. 3O$ 3 Emergency Telephone No. <br /> 1 Contractor Licence No. <br /> Applicants Name (Print) cC` S f� Title - Date 11 L7 F <br /> Please check Applicable Category (14)and Fill in the Required Information Q�I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) # <br /> For July 1, June 30, 19 - Disposal Sites - <br /> Description(Make/Yr., Color) <br /> CAL. License No. CAL. License Renewal No. Oi <br /> Serial No. <br /> Capacity Gal.,Weights & Measures No. <br /> I, � <br /> Equipment Parking Address <br /> 2. 0 PUMPER YARD <br /> For July 1, June 30, 19 - <br />'I - <br /> No. of Vehicles Stored ' <br /> No. of Chemical Toilets Stored i <br /> 3. 11 PERCOLATION TEST i <br /> i R.S.or R.C.E. No. <br /> i R.S. or R.C.E. Name <br /> Test Location t Test=_Date/Time <br /> 4. EVSANITATION PERMIT <br /> JobAddr9q/1-ocatiorl <br /> � <br /> AddressOwner <br /> 1 SEPTIC TANK., ❑ CESSPOOL BLEACHING FIELD ®'SEEPAGE PIT ❑ PACKAGE PLANT i <br /> M-PERMANENT' ❑ TEMPORARY @NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <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 <br /> Where Certified <br /> Operator Name <br /> Plant Location <br /> Plant Capacity }No. Units Served <br /> 7. El LAUNDRY For July 1,-June 30, 19 - 1 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft` <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 1 <br /> 1 <br /> I hereby certify that I have pre ared this plication and that the work will be'done in accordance with San Joaquin County <br /> ordinances, state laws, and and reg ti s the San Joaquin Local HealtF,District. <br /> P <br /> APPLICANT'S SIGNATURE X <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT PER-SITE EACH ❑ January 1 &Received By January 31 C1 July 1 8 Received By July 31 T <br /> Il4 REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> l FEE S <br /> LESS <br /> PRORATION <br /> PLUS t <br /> PENALTY <br /> r[ OTHER <br /> { OTHER <br /> F" M, <br /> Received by Date Receipt N. Permit.No. Issu nce Date Mailed �F <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVIGE 1601 E.HAZE SON AVE.,P.O.Box 20 CA 95-- <br /> IZ' <br /> E <br />