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,.�. - _ <br /> - Appricatlons WIII Be Processed When Submitted Properly Completes.ox�,e +�,..m•. •--- <br /> -- APPLICATION <br /> (Far Non Transferable,Revocable,and 5uspehdabiu) SEPTAGE , <br /> f ENVIRONMENTAL HEALTH PERMIT 4 <br /> LIQUID WASTE <br /> Application is erepy m de to carry o uslnass in the jurisdictional area of the San Joaquin Local Health District <br /> 446, �� Address s� <br /> ,n Business Name(Dl3 ) r- <br /> .•- „-� Address <br /> Owner <br /> 41 <br /> Firm Partners.Addresses and Telephone Number �l Emergency Telephone No. <br /> eBusiness Telephone No._ !9 I'll IIIIj 1, 1111111 1111.11 F <br /> Contractor Licence No. Title -� -- Date &� <br /> Applicants Name (Print) <br /> Please check Applicable Category(1-T)and Fill In the Required Information <br /> 1, 0 PUMPER VEHICLE PERMIT REGISTRATION(DFOR EACH isposal VEHICLE) ` <br /> For July 1, _June 30, 19 <br /> I <br /> Description(Make/Yr.,Color) CAI_.Lice:se Renewal No. t <br /> Serial No. GAL.License No. � <br /> Gal.,Weights&.Measures No. <br /> Capacity <br /> Equipment Parking Address - <br /> 2. 0 PUMPER YARD + <br /> For July 1, — June 30,i9 <br /> No. of Vehicles Stored <br /> I I <br /> No. of Chemical Toilets Stored <br /> 3. 0 PERCOLATION TEST R.S.-or F.C.E.No. _ <br /> R.S.or R.C.E.Name Test Date/Time <br /> Test Location <br /> a. ❑ SANITATION PERMIT {. <br /> la a <br /> Joke Address/Location <br /> Owner Address <br /> ' CESSPOOL LEACHING FIELD 17 S PAGE;P "f'' d0 PACKAGE PLANT <br /> OTHER❑ SEPTIC TANK Ali <br /> t <br /> El.PERMANENT - JD.TEM POPARY.... 13 AEW _ . �- m✓'-��; <br /> 5. © <br /> CHEMICAL,TOILETS For July t;-June 30,19 <br /> Type Constructlon Disposal Site = <br /> I <br /> No.of Units — Equipment Storage/Cleaning Location(s) <br /> , <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 'flNhere Certified <br /> .._..r�.�.... - . <br /> Operator Name <br /> I Plant Location p . <br /> No. Units Served I <br /> i Plant Capacity <br /> 7. 0 LAUNDRY For July 1,-June 30,i9 tf ti ".r} j; <br /> SIZE: ❑ Less Than 1,000 Sq.:Ft., ❑ More Than 1,000 S'Ft.` <br /> r ; <br /> L7 DRY CLEANING,Chemicals Used/Amoun~ <br /> I hereby certliy that f have.p er pared this application and that the work wiN-be dol accordance with San JQaqu±nrCounty <br /> I ordinances,state laws,and ls and re_qUIat1I of the San Joaquin Local Health=District. <br /> • i <br /> APPLICANT'S SIGNATURE �— <br /> I �y"� <br /> l i S AII FOR DEPARTMENT USE-ONLYu <br /> f Feb Is Due: ❑ ANNUALLY ❑ P,ER;UNtT Il PER S1TE ��- A •Jry 1 &Ri3ceWed.By January 3� ❑ July 7 8.Raceiv REM1Td By uly 37 <br /> Y 1,f y ti BILLING REMITTANAMOUNT DUE CHECKED <br /> BASE EXPLANATION <br /> DATE DATE .REMITTED AMOUNT <br /> FEE - <br /> LESS j <br /> PRORATION t' <br /> PLUS • « �r <br /> PENALTY _ _ _ �.—..--�- .,•.•• ^... ._."' <br /> OTHER <br /> 1 OTHER - <br /> Issuance Data Mailed Delivered <br /> Received 4y Date Receipt Na. 'Permit No. - <br /> I APPLICANT=aETUFiN ALL COPIES TO: ENVIRONMENTAL HEALTH PERUtT/SERVICES t601 E.HAZELTON AYE.,P.O.Bos 2004 S OCCK,-ON,CA 95201 <br /> , <br />