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5- t-1 .-.A,,...y.E.}�.aCtR•:1:�`e s5'�"',ti , .-1�`no..%: r t ne ,.1 -'F. m-..r�e.reRM <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sun To Sign The APPlkalion. <br /> APPLICATION <br /> (For Non-Transtemble,Ravo"ble,and Srependable) - SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT - <br /> LIQUID WASTE <br /> ApplicatiDw6 hereby ade t0 ryon buss ass in the jurisdictional area of the� ,p,Jo 'in Lpcal H allh Distnc <br /> Business Name(OBA)�^:A �,� "' Address—; >X ���-----C-G�'T� <br /> a <br /> Owner Address <br /> '-' Firm Partners,ele hone No. and Tel hone�Qumban <br /> Y1' Business Telephone NO. jj � Emergency Telephgna NO. <br /> Contractor Licence NO. <br /> L Applicants Name(Prins) Title Date <br /> Plow check Applicable Category 11.7)and Fill In the Required Informa30n - - <br /> 1. 0 PUMPER VEHICLE PERMIT RCGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30,19 Disposal Sites <br /> ..Description(MakWr.•Color) _ <br /> Serial No. --+ ----_-- CAL License No. --_ " - _CAL License Rarlawar Nd. <br /> Capacity Gal.,Weights&Measures No. <br /> Equioment Parking Address <br /> 2, 0 PUMPER YARD <br /> For July 1,_June 30. 19. <br /> No.of Vehicles Stored . <br /> No.of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST - <br /> R.S"or R.C.E.Name R.S.or R.C.E.No. <br /> Tes:Location Test Date/Time <br /> a. ❑ SANITATION PERMIT - <br /> -i Job Address/Location <br /> Owrlar Address `Q <br /> ;."XaFPTIC TANK ❑ CESSPOOL A LEACHING FIELD 0 SEEPAGE PIT O.PACKAGE PLANT <br /> G PERMANENT ❑ TEMPORARY >t NEW 0 REPAIR 0 OTHER <br /> s. O CHEMICAL TOILETS For July 1,-June 30, 19__ - <br /> ;_ Type Construction - Disposal Site <br /> No.of Units - Equipment Storage/Cleaning Locations) <br /> 0 PACKAGE TREATMENT PLANT For July 1,-June 30, 19 - <br /> Operator Name Whom Certified <br /> Plant Location <br /> _'. Plant Capacity No.Units Served <br /> 7. ❑ LAUNDRY For July 1.-June 30, 19 <br /> SIZE: 0 Less Than 1,000 Sq.FI.. 0 More Than 1,000 Sq.Ft. - <br /> C DRY CLEANING,Chemicals Used/Amount/MO. <br /> I hereby certify that I have pre red this application and that the work will be done in accordance with San Joaquin County <br /> ordinances.state laws,and m and r4gglaC sol me n Jo uiAn Local Health District <br /> APPLICANTS SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee la OW: ANNUALLY 0 PER UNIT 0 PER SITE 0 EACH CIJanwry I a R«enea By Ja^wry 31 ❑JWy I n R«epee ey J.",31 <br /> REMIT <br /> BASE EXPLANATION I BILLING REMITTANCE I = AMOUNT OUE CHECKED <br /> DATE DATE REMITEO AMOUNT <br /> - <br /> FEE <br /> SA <br /> ! ,IT�.I I <br /> PENALTY <br /> OTHER I•+ <br /> 79- '7/S <br /> �. OMe RKFPINM1 Re/eYI NO. IYI,eK! MY MeMp DeIMI« <br /> pMOANT�RaTp11R/.LL COMES TO: ERYIROMMFNTLL HEALTH IEI1MITge11y,CEe 1 Wl L NAZELTON AVE-P.O.aye ff01 STOCMON.CA"NI <br /> 45;�? a <br />