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Applications WIII Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' (For Non-Transferable, Revocable,and Suspendable) <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> OF Business Name(DBA) &S r,.c� Address ,Ue.74e2S.�v�'l: <br /> aOwner Address_.Z`,eII114A x+111— f— <br /> Firm Partners, Addresses and Telephone Numbers <br /> a. Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> L Applicants Name (Print) Title Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information 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. -+ E <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No, of Vehicles Stored <br /> No. of Chemtcal'foitets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E. No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMIT <br /> Job Addres /Location.. <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL WLEACHING FIELD-:El SEEPAGE PIT EF PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY; jrNEW. IrREPAIR ❑ OTHER t <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 Y <br /> Type Construction 4" `� 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 F <br /> Plant Capacity_ ��► ^: ` a 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 /> rter(Inmanwarmer licsnsed ag6nt's amesuijectt wr erfifierthpfollnwi 5i"Icertity that inibepertermanceoftheworkferwhichthis*mitisissuedIshallnetemployanyper�,j;i <br /> n ntra mariner a5 to became su .conn c V, 'Sj a,'s .0moerisatlon 12t;s R'California,' <br /> Contractor's airing or saga-tentrattir: �: <br /> m Ig Y a CErtitrea t#1e foll�lv,n,: "i certify That in ttre pArfGrriance ci ttt yrer'r,far v 1 ir. this perrrit is issued,l;haft <br /> D y persons Sl Nett to 1 Ufkm&r;cornpeRst.,7x1 tan's ,t Galitursrir:' <br /> � A <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 rea " ns of the San Joaquin Local Health District; <br /> APPLICANT'S SIGNATURE X <br /> r <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE � 4:1 cfcz� <br /> LESS <br /> PRORATION <br /> PLUS `} <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recei by Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boy 2009 STOCKTON,CA 95201 - <br /> (A <br />