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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made tocaf ry on business in)he jurisdictional area of the San Joaquin Local Health Di trict <br /> ,Business Name (DBA) F1'. 1'✓ Siegfrjec k A-ssacl afe—S Address4d4s CQ"na)a � VP <br /> a Owner Ione Trey CI^ee Vin e/-ds Address P� Q• ,Rex L397 <br /> L) Firm Partners, Addresses and Telephone Numbers s-q 9 — w <br /> CL <br /> Business Telephone No. g43' Z�2� Emergency Telephone No. <br /> Contractor Licence No. 1 <br /> L Applicants Name (Print) Sfan dS/7l7}L� Title Date 6 —Z 7—90 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <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 S d <br /> 3. 0 PERICOLATIO1EST [VTS — 13S <br /> R.S. or R.C.E. Name e R S flr R.C.E. No. 17351 <br /> Test Location 888 8 South Mur by Rad Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <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 /> Home owneror licensed agent's signature certifies the following:"I certify}that Nn the performance of the workfor which this permit is issued,I shall not employ any person <br /> in such manner as to becurle subject la%rS yiCetita n;;, ' <br /> Contractor's hiring or sub-contracting aigneture certifies tate following: -9 certiy ihat in itte performance of the work for which this permit is issuecL l shall <br /> employ persons subject to workman's compensation laws of California." <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,, and rules and <br /> ��r}jegul tion of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑F.ER UNIT ❑ PER..SIJE -E.-nl EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE MITTED AMOUNT DUE CHECKED <br /> 1 q AMOUNT <br /> FEE �o 7-q 9 y' <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �2 <br /> ?f�? -17- o <br /> Receiv by Date Receipt No. I Permit No. Issuance Date Mailed Deliver d <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boz 2009 STOCKTON,CA 95201 <br />