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Applications Will Be Processed When SuAPPL`CATION + <br /> (For Non-Transferable,Revocable, and Suspendable) SEPTAGE <br /> �= I ENVIRONMENTAL HEALTH PERMIT 0-71 OSb .-2-5 I <br /> R3•S- <br /> LIQUID WASTE <br /> Applicati is hereby etoXa� on busine in the jurisdictional area of th the San }{ealt��is r <br /> +D _ 00� <br /> in the <br /> IT _Address /� �' <br /> Or Business Name (DBA) Address <br /> i Owner �� <br /> a <br /> 1 Firm Partners, Addresses and Tele hone Numbers <br /> 5 f 6 Emergency Telephone No. <br /> aBusiness Telephone No. 3 / F— /7-77 <br /> 1 Contractor'Licence No. f �� 1' Title ST Date <br /> L ApplicaRts Narne�(Print)- <br /> f 1 <br /> Please check AppIGible.;,Cate9ory(1-7) and Fill in the Required Information <br /> 1, ❑ PUMPER VEHICLE�PERMIT REGISTRATION (FOR EACH VEHICLE) 1 <br /> Disposal Sites <br /> For July 1, June 30, 19 <br /> Description(Make/Yr., Color) CAL. License No. CAL. License Renewal No. <br /> Serial No. <br /> Capacity Gal.,Weights &Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> f <br /> No. of Chemical Toilets Stored Q 1. <br /> 3. ❑ PERCOLATION TEST R.S. or R.C.E.No. -Q <br /> i' R.S. or R.C.E.Name I <br /> Test Date/lime <br /> Test Location �} n <br /> k 4. %SANITATION PE III IT «- r71L� � o <br /> Job Addre s/Lo ation L� �—ec &�� <br /> F t T Address <br /> Owner y LEACHING FIELD 13 SEEPAGE PIT ❑ PACKAGE PLANT i <br /> SEPTIC TANK ❑ CESSPOOL `� ❑ REPAIR 13 OTHER <br /> PERMANENT <br /> El TEMPORARY ' NEW <br /> 5, ❑ CHEMICAL TOILETS For"July 1, -June 30, 1Disposal Site <br /> Type Construction <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> g, 13 PACKAGE TREATMENT PLANT For July 1, -June 30, 19_rWhere Certified <br /> Operator Name <br /> i• <br /> ' Plant Location No. Units Served <br /> i Plant Capacity <br /> -1. ❑ LAUNDRY For July 1, -June 30,19More Than 1,000 Sq. Ft. <br /> If SIZE' ❑ Less Than i,000 Sq. Ft., <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. � <br /> o��� <br /> I hereby certify that I have prepared this application and that the work will done in accor ance with San Joaquin County <br /> ordinances, state laws, an es and regulaf ns of th San Joaquin Local 1th District. <br /> jAPPLICAIN(T'S SIGNATURE X XNNw. 4 �hQ <br /> 0^4 FOR DEPARTME 'USE ONLY <br /> 1 "'"" 'i]January S&Received'BY January 31 © July 1 &Received By July 31 <br /> Fee is Due: ❑.ANNUALLY ❑ PER UNIT ❑` PER SITE ❑ EAC—" REMIT <br /> BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> BASES...--—EXPt--ANAT16N� �__DATE DATE REMITTED AMOUNT <br /> FEE <br /> k <br /> LESS <br /> PRORATION It <br /> PLUS . - <br /> PENALTY - <br /> r <br /> OTHER -7 <br /> `V17 7 dQ�Vr <br /> c <br /> _ Receipt No. ermit No. <br /> Issuance D to Mailed Deli eyed <br /> Received by Date - igp1 E.HAZELTON AYE.,P.O:BOM 2009 - STO KTON,CA 95207 <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERYICES - --r <br />