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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 />{ Applicat' is ereby a to c r on business in the jurisdictional area of the S Joa uin I It is i t # <br /> 4 y Business Na BA) Addr41 <br /> ss 0 <br /> i Owner Address b <br /> J Firm Partners, Addresses and T le hone Numbers <br /> aBusiness Telephone No. a�- Emergency Telephone No. <br /> _J Contractor Licence No. M <br /> Applicants Name (Print) --- .Title - K Date J <br /> Please check Applicable Category (1- and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE)•``" <br /> For July 1, - June 30,19A` ,' Disposal Sites - n- <br /> Description(Make/Yr., Color) T <br /> Serial No. y CAL. License No. CAL. License Renewal No. N <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 ' 'i1 !I <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 /> Test LOcVOn ti } Test Date/Time"" <br /> 4. ANITATION PERMIT V I <br /> Job Addres Ion N`t <br /> Owr1er { Address _ <br /> S IC TANK CESSPOOL 10—CE�C_r64fNG FIELD EEPAGE P1T- ,❑•PACKAGE PLANT x <br /> PERMANENT 11TEMPORARY D'NEW t ❑ REPAIR ❑ OTHER S <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Sit <br /> No. of Units ..EquiOenent.Storage/Cleanin`g Location(s) - <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30; 19 <br /> Operator Name a 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 /> 1 • <br /> t � <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 d gulations a an Jo in Local Health District. <br /> APPLICANT'S SIGNATURE X 77 <br /> FOR DEPARTMENT USE ONLY <br /> _ Fee Is Due: 11 ANNUALLY ❑ PER UNIT_ .❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> ' <br /> REMIT <br /> BASE <br /> BASE EXPLANATION BILLING REMITTANCE $PATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE ,.. <br /> LESS <br /> PRORATION �� - �""`�..� +✓ <br /> PLUS <br /> PENALTY <br /> OTHER tt <br /> OTHER <br /> ' Received by Date Receipt No. Permit No., Issuan aia Mailed Delivered <br /> APPLICANT—RETURN ALL COPT O: ENVIRONMENTAL HEALTH PERM ITISERVICES 1601 E.HAZELTON AVE.,P.O.Bo:20D9 STOCKTON,CA 95201 _ <br />