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Applications-Will Be Processed When Submitted Properly Completed. tiesure 10 atgn >Inen�rNrnosry <br /> APPLICATION <br /> (For Non-Transferable, Revocable,'and SusperidabFdy� SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicabon is hereby mad to car n b s' es ' the ju is ctionaI area of the an Joaquin local Heal h District+ <br /> (.� LK ddress <br /> Business Name (DBA) r <br /> Address - <br /> zOwner <br /> 2 Firm Partners, Addresses a phone Numb rs <br /> a Business Telephone No. Emergency Telephone No. <br /> S <br /> a Contractor Licence No. r ` <br /> r r �, Tltle,. 'r Date <br /> <'Applicants-�Name(PI.ant)I-A -^ ' <br /> Please check Applicable Category (1-7)and Fill in the Required In F r {1f1 <br /> Cr For13 ;PUMPER VEH,une 30 AM ITi REGISTRATION (FOR EACH VEHICLE) <br /> - -'' _. — Disposal SitesJuy - <br /> Description(Make/Yr.,Color) CAL. License Renewal No. <br /> Serial No. �M CAL. License No.<' * r' <br /> Capacity �M, Gal.,Weights &Measures No. <br /> E ui ment Parkin Address <br /> 2. ❑ PUMPER YARD it <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored i <br /> No. of Chemical Toilets Stored •--� <br /> •'3 41 PERCOUATION-TEST <br /> R.S. or R.C.E. No. Q <br /> R.S.or R.C.E. Name l� <br /> Testi <br /> .Location II Test Date/Time { <br /> � r. S <br /> 4. 0 SANITATION PERMi <br /> � 4 <br /> Job F ddress/Location ) <br /> Owner Address r� <br /> ❑ S,EPTIC TANK ❑ CESSPOOL ;'. ACHING FIELD Q-SEEPAGE;PIT[•`❑,PACKAGE PLANT• <br /> m i. fi " ❑ OTHER <br /> ❑ TEMPORARY' L'u NEIN - -' �' EPAIR C <br /> ❑ P.ERMANENT <br /> 5. CHEMICAL TOILETS For.July 1,-June 30, 19 � <br /> Disposal Site <br /> Type Construction I a { r>1 <br /> E ui mentl:.Storage/Cleaning Location(s) <br /> No. of Units . q p � <br /> 6. ID PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> i, Where Certified <br /> Operator Name II ( ( f <br /> Plant Location <br /> c Ij No, Units Served <br /> Plant Capacity <br /> 7 I' <br /> 13 LAUNDRY 1 For July 1, -June 30, 19 { <br /> t ❑ More Than 1,000 Sq. Ft. f <br /> I SIZE: ❑ Less Than 1,000 Sq.{Ft:, ,_ <br /> ❑.DRY CLEANING, Chemicals Used/Amount/MO. <br /> L <br /> � t i hereby certify that i have prepared this application and that the work will be done in'accordance with San Joaquin County <br /> ordinances, stat rules a re ' lation f the an Joaquin Local Health tact";_. r" } <br /> ! { � ' I <br /> I APPLICANT'S SIGNATUR <br /> (�I_15 i <br /> + FOR DEPARTMENT USE ONLY, <br /> ' 1 .. N <br /> 3-E t x � a�: <br /> d Bi <br /> Fee Is Due: El ANNUALLY !, ❑ PER UNIT' ❑ PER SITE -� [] EAC_ <br /> H_.,��❑,January 1_&Received Bydanuary 31 ❑ ly 1 &-Recei`v REMITuIy 31 <br /> :I. 'BILLING REMITTANCE $ AMOUNT DUE CHECKED , <br /> tt? BASE EXPLANATION - DATE. DATE REMITTED AMOUNT <br /> i h <br /> r 1� <br /> FEE <br /> LESS <br /> 3"PRORATION ,q l <br /> y 1 <br /> - PLUS <br /> PENALTY <br /> .� _ <br /> OTHER - . <br /> .i� � � , - <br /> OTHER <br /> ( 'Permit Nn Issuance Date ailed Delivered <br /> l Received by Date Receipt No. =-�; _ x, I . " ,, 4, - <br /> .3 i f ' ' 1601 E.HAZELTON AV ox 2009 STOCKTON 95 0 <br /> APPLICANT—RETURN ALL COPIES TO: 'ENVIRONMENTAL HEALTHPERMITlSERYICES� <br />