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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The`Appl!cation. f <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE _ <br /> Application is he by}}by mp e to carry on business in the jurisdictional area of-the San oaquin Local Health District <br /> y Business Name (DBA) /TPSI+ ^PX,e7C? � Address r &_ 6 <br /> aOwner ,. -yam Address'µ W A <br /> 2 Firm Partners, Addresses and Tel hone Numbers <br /> CL <br /> Business Telephone No. �✓ _ Emergency Telephone No._. I )d, <br /> — _ G^ • . <br /> -J Contractor Licence No. - - <br /> LApplicants Name (Print) /1/J C .(/' <br /> Tltle. Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information-„ y I <br /> f. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) k I. <br /> For'July 1, -- June 30, 19 -"Disposal Sites -_-Description(Make/Yr., Calor) <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity I Gal., Weights & Measures No. <br /> Equipment Parking:,Address <br /> 2. ❑ PUMPER YARD - 4 <br /> For July 1, 01 June 30, 19 t <br /> z It F ` <br /> No. of Vehicles Stored r <br /> No. of ChemicalToile#s Stored } <br /> 3. ❑ PERCOLATION TEST i <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT / � , <br /> Job Address/Locati d^ <br /> Owner E36 P 'j LP -2ev /-2- j <br /> Address - ! 44.,' <br /> 12 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD 11 SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11 PERMANENT >40 TEMPORARY El _E]..- t_L]LREPAIFI 11QTHER <br /> 5. El CHEMICAL TOILETS' Fbr'July 1-, -June 36,"l 9 <br /> Type Construction ��'*4 _ Disposal Site <br /> No. of Units x ' tEquipment'Storage/Cleaning.-Location(s) �' I <br /> 6.p❑ PACKAGE TREATMENT PLANT For July 1 June 30, 19 _ <br /> O erator Name - - <br /> nn9l <br /> _ _ Where Certified <br /> plant Location - �,Cf <br /> Plarit CapacityNo. Units Served <br /> 7. LAUN6RY'"`Fbr u1y`1xJu a 30"j-g,_ — <br /> SIZE; [ILe§s Than],006 Sq.:FtT ❑,More Than 1,000 Sq. Ft. <br /> ❑ 1)RY�CLEANING7tChemicals-Used/Amount/Mo. l <br /> I hereby certify that I have prepared th"is application and that the work will be done in accordance with San Joaquin County - <br /> ordinances, state laws, and rules and �ulati soft a San oaquin Local Health Dis t. <br /> 114 <br /> LICANT'S SIGNATUREX� <br /> y <br /> FOR DEPAR.T,ME_NT'USE ONLY <br /> '$ Fee Is Due: ❑ ANNUALLY ❑ PER UNIT �❑ PER SITE ❑ EACH ❑ January 1 &Received56 Januar 37 <br /> _ Y Y ❑ July 1 &Received By July 31 <br /> { ��~�� ry --- BILLING LL_�� M r+ —�REM1T X <br /> �'* BASEEXPLANATION� �TIREMITTANCE $ �� T <br /> �....DATE++�..--. REMIT-TED <br /> AMOUNTD CHECKED <br /> —AMOUNT-^"""' "^ <br /> FEE i q} Ick <br /> LESS <br /> PROHATION— <br /> PLUS <br /> PENALTY ' .. <br /> OTHER <br /> i <br /> OTHER <br /> Rec�ty , ate Receipt No. Permit No. Issuance Dat Mailed <br /> Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1601 E.HAZELTON A .O.Box 2009 STOCKTON,CA 95201 <br />