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M Applications Will Be Processed When Submitted Properly Completed. BeSureTosign Inewppllrauvr . <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> ct <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Di�tri � i <br /> r / t 1 .;� .n�r4tif/f Address E,tll h + <br /> m Business Name (DBA) <br /> t~ Address <br /> aOwner2 Firm Partners, Addresses�ad =phone Numbers <br /> d Business Telephone No. <br /> e l Emergency Telephone No. <br /> a <br /> Contractor Licence No. Title Date <br /> L Applicants Name (Print) <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 - Disposal Sites <br /> Description(Make/Yr., Color) CAL. License Renewal No. <br /> Serial No. CAL. License No. y <br /> Capacity _Gal.;'Weights & Measures No. <br /> �- <br /> Equipment Parking Address _ <br /> 2. ❑ PUMPER YARD sa <br /> June 30, 19 f <br /> For July 1, _ <br /> No. of Vehicles Stored,- m <br /> No. of Chemical Toilets Stor <br /> 3. -❑ PERCOLATION TEST _�»— <br /> R.S. or R.C.E. No.. � <br /> R.S. or R.C.E. Name <br /> Test Date/Time <br /> Test Location � <br /> 4. ❑ SANITATION PERMIT _p�. �a � � V/-k � <br /> Job Address/Location <br /> Address : <br /> O.wner A x1l 4613 PACKAGE PLANT <br /> ❑ PERMANENT <br /> _SEPTIC.TANK ❑ CESSPOOL ;LEACHING FIELD 11 SEEPAGE PIT <br /> ❑'TEMPORARY I":NEW 11REPAIR 11OTHER f <br /> � <br /> 5. ❑ CHEMICAL TOILETS For July,1, June 30, 19 <br /> TypConstruction Disposal Site <br /> e <br /> No. of Units Equipment Storage/Cleaning Location(s) i <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 1 <br /> _ Where Certified <br /> Operator Name <br /> Plant Location <br /> No. Units Se4cl- <br /> Plant Capacity <br /> 7. ❑;LAUNDRY For July 1, -June <br /> SIZE: El-Less Than 1,000 Sq. Ft., ❑ More Thari 1;000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> Thereby certify-.that I have prepared this application and that the work will be done in accordance with San Joaquin_County <br /> `ordinances, state laws; and jules and.regulations of the San Joaquin LacalryHealth District. T <br /> APPLICANT'S SIGNATURE X <br /> R FOR DEPARTMENT USE ONLY <br /> "f=ee IS Dtle'"�-ANNUALLY EI-PER UNIT -' PER'SITE-�"' "❑'EACH' ' '❑ Sanuary t&,Received'By January'31 ❑ July-1-&'Receiv REMITJu*31- <br /> x` BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT <br /> PEE <br /> LESS <br /> ,PRORATION _ <br /> PLUS ! <br /> PENALTY <br /> OTHER a <br /> OTHER <br /> -7 —C:i3 11 7 , <br /> Permit No. Issuance Date Mailed ve d <br /> Received by Date Receipt No. <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON AVE.,P.Q.Bow 2409 STO TON,CA 9520 <br />