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APPLICATION <br /> or Non-Transferable, Revocable, and Suspends, SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applica Ion Is hereby made to carry on business in th uradi ti In of the San Joaquin Local H alth Di¢tact T <br /> IpBusiness Name(DBA) ��LZN ��L ���.T,{�d{ess S �� C L � L <br /> i Owners,,f'_'�VU\I �,5 �LL Address <br /> Firm Partners, Addresses and1e hone Numbers <br /> `Business Telephone No. a �. Emergency Telephone No. <br /> I Contractor Licence No. LF_ p` <br /> Applicants Name (Print) -F NNIJp� :X:"% Title ate Q r� <br /> Please check Applicable Category (1-7)and Fill In the Required Information <br /> 6.1. 0 PUMPER VEHICLE PERMIT REG�TRATION (FOR EACH VEHICLE) <br /> For July 1, June 30,-19 Disposal Sites '1 <br /> LDescription(Make/Yr., Color) <br /> Serial No. CAL. License No. t GAL. License Renewal No. ' n <br /> Capacity. _..-. . . _. Gal.;Weights&-Measures N( . <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> r <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No.U.Cl��a�mical Toilets Stored - <br /> �3. 11,PN1COLATION TEST <br /> R.S. or R',C.E: Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> `C. ❑ SANITATION PERMIT <br /> Job Address/Lo ation <br /> Owner C :Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL LEACHING FIELD, SEEPAGE PIT ❑ PACKAGE PLANT <br /> aw❑ PERMANENT ❑ TEMPORARY NEW REfyAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 , <br /> Type Construction Disposal Site <br /> .No. of Units Squipn)errt Sto4y1Cleaning Location(s) <br /> 6. ❑ PA KAGE TREATMENT PLANT For July 1, -June 30, 19 I <br /> Operator me Where Certified <br /> _Plani Location Oce <br /> Plant Capacity r No..Units Served <br /> 7. ID LAUNDRY.{or 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 /> Mooae..*eT erResneedagBrrt s sfgnatumeerd6ea roafoaowing:"I carpiirrthat in the Oerlarmance of the work for which this permit is issued,l shall not employ any parson <br /> 10 Id"moPmer as ss become Subject to workmanS MMIll nSMieR laws of Cal'rfenla.' <br /> Com" v a 11t11hg nT w,1`-e0l ffn9 aigrlaNro c* title. fns fallowing: "1 certify that in the performance of the work for which INS permit is Issued I shall ,S <br /> Cap"-person fyflieefhworkman's compensellInfa slatLa6brpla.' _S <br /> I hereby ertify th have'pr aced thi tion an t t the wo will be done in accordance with San Joaquin County - <br /> ordinances, state law , a ru s an reg Is In f t oaquin c Heal District. <br /> .APPLICANT'S SIGNA <br /> I+ FOR DEPARTMENT USE ONLY <br /> Fee Is Due:❑ ANNUALLY ❑ PER UNIT p❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 0 July 1 a Received By July 31 <br /> REMIT <br /> QASE EXPLANATION <br /> BILLING REMITTANCE f <br /> AMOUNT DUE CHECKED - <br /> ear, DATE DATE REMITTEEDD AMOUNT <br /> FEE <br /> LESS - <br /> L PLUS 7t C/rV <br /> PRORATION <br /> PENALTYPLATE <br /> OTHER <br /> L <br /> OTHER <br /> f R�oy are le <br /> ceipt o. arm a. Issuance Date Mailed Delivered <br /> ` APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95 <br />