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---- APPLICATION L <br /> or Non-Transferable, Revocable, and Suspenda SEPTAGE <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Appli n is hereby m de to arry on busine in a fur dtctional area oft �Joa. Local 7[�h istric `j <br /> yBusines ame (D } I Address <br /> z Owne Address <br /> a <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Contractor Licence No. - <br /> L GO <br /> Applicants Name (Print) Title Date <br /> Please check Applicable lg�ory(1-7) and Fill in Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) a. <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL, License No. CAL. Liccnse Renewal No. <br /> Capacity Gal., Weights &Measures No. <br /> Equipment Parking Address:t <br /> 2. ❑ PUMPER YARD <br /> For.July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or 9.C.E. Name R.S.or R.C.E.No. <br /> Test LKo ation 'Test-Da te/Time <br /> 4. L� SANITATION PERMIT• ? <br /> Job Address/ ion q , <br /> Or <br /> Address J <br /> ❑ TIC TANK CESSPOOL ❑ LEACHING FIELD SEEPAGE PIT PA AGE PLANT .� <br /> L�1 PERMANENT ❑ TEMPORARY ❑ NEW g-REPAIR _ © OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 �1 <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 /> Operator Name Where.Certified <br /> Plant Location - - <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less.Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> i <br /> I hereby,certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, an rules and r ula 'ons of the San Joaquin Local Health District, <br /> I APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Feer'Is Due: 11ANNUALLY ❑ PER UNIT ❑ PER SITE ElEACH ❑ January 1 &Received By'January 31 - ❑ July 1 &Received By July 31 <br /> -REMIT <br /> I - BILLING REMITTANCE $ <br /> BASE EXPLANATION GATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> jV <br /> FEE _ C <br /> LESS k <br /> PRORATION_ <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. - Permit No. Issuance Date- - Mailed Delivered <br /> -APPLICANT-RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P 0 Box 2009 STOCKT ON,CA 95 1 - <br />