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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign t ne nppncaxion. <br /> APPLICATION <br /> (For Non-Transferable,Revocable,and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> ?DO2 nJ E K1 ffDPE e1� f LIQUID WASTE 0o I -' P �7 <br /> Applicati n is he�eb�mad o carry on bu fines 'n t juri dictional area of tp�,�}qa Joaq Local Health Dl1's <br /> m Busines ame (DBA) AddressO� `� -'--- <br /> i Owner Address <br /> a <br /> Firm Partners,Addresses a d Telephone Nu era pa <br /> aBusiness Telephone No. Emergency Telephone No. 1 <br /> Contractor Licence N _ <br /> Applicants Name (Print) Title Date <br /> Please check Appllcabl ategory(1.7)and Fill In the Required vormation W <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, ,June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. _ CAL License Renewal No. <br /> Capacity Gal., Weights&Measures No. <br /> Equipment Parking Address <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 R.C.E.Name R.S.or R.C.E.No.. <br /> Testi Lon Test Date/Time <br /> a. Or-SANITATION P IT <br /> Joh Addr Location <br /> pr{]w/t�r Address <br /> Po PTIC NK ❑ CESSPO L T�L ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> VRMANENT ❑ TEMPORARY IEt'NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 to' <br /> *No. <br /> Construction Disposal Site11- <br /> No.of Units Equipment Storage/Cleaning Location(s) Z <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 A <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq. Ft. �o <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <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,a rules and r ula" ns of}trp S Joaquin Local Health District. ' <br /> APPLICANT'S SIGNATURE X � /*0, ! ' <br /> FOR DEPARTMENT USE ONLY <br /> Fee 19 Due: Q ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By emery 31 my 1 8 Received By Jury 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ OUNT DUE CHECKED <br /> DATE DATE R TT AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> • OTHER <br /> OTHER <br /> Receivod DY Date RecerPt NO. �r�mli f� ��Date, Mailed Del d j <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HA ELTON AVE.,P.O.aax moa STOCKTON,CA 95101 <br /> Ccd b Rei. 4 A '13) <br />