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y Applicallons'Wlll Be Processed When Submitted properly Completed. Be Sure To Sign The Application.
<br />APPLICATION �_1 ,7;;1-
<br />r. b M 'vr, (For Non -Transferable, Revocable, and Suspendable) SEPTAGE
<br />ENVIRONMENTAL HEALTH.PERMIT
<br />LIQUID WASTE
<br />Ap'plicaLN is hereby made Vb carryon busi _ess•In,o% nsctional area of th n Joa In Local Health Distnc t
<br />a Susine s ame (DBA) id<- sC9T�_ AddressytQ t}�%�'-%_ F —
<br />aOwne� — Address�..�
<br />73
<br />Firm Partners, Addresses an. dTelephone umbers —_— —
<br />a Business Telephone No. —cam=J—'_t� _ Emergency Telephone No.
<br />Contractor Licence No,
<br />� l a;
<br />x
<br />a
<br />Applicants -.Name (Print) 1= Title I/J.V._�- Date - 7=�0� �
<br />�Please•ctledk Aplicebte C1 _ ory•(1-7) and Fill I eRequired Information
<br />❑, ��. ••� }
<br />y� 1. �• PUMPER VEHICt E�P 'AMIT REGISTRATION (FOR EACH VEHICLE)
<br />For July;1,1 ' n) 'k Juhe 30;,19�_.w Disposal Sites — _ — --(A
<br />I D9 c�ipdo I (Make%Yr._, Colbr)
<br />4Serial No? V �r �r •' CAL. License No. , —_ _ — _ CAL. License Renewal No.— —vim
<br />`'>✓apac'ity `=n' -�� �' Gal., Weights & Measures No.
<br />Equipment Parking Address-
<br />2.
<br />ddress 2. ❑ PUMPER YARD t
<br />For July 1,— ."i June 30, 19 _ -
<br />No. of VehlCles Sto`ted
<br />No. of Chefnical T6ilets Stored — —._ — --.-- - — — —
<br />» -3,i ❑ _pERtOLATION TEST
<br />RtS: or R.C.E. Narna _ _ _ R.S. or R.C.E. No._ .
<br />14s Lo' tion �� Test Date/Time — —L
<br />_:-4.� Ifct SANITATION PERMIT
<br />Job
<br />1 c�
<br />Job Addr /L0�C]
<br />�?v7 y� y�J/ Q Address _ �V,�,PTIC TASPOOL`; J: ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT I
<br />WFERMANENf ❑ TEMPORARY EW 11 REPAIR � ER' `J�^^V r
<br />:�;❑ C�IEMICAL TOILETS Foe July f; JdneS30, 19
<br />Tape Constructi0lf t Disposal Site
<br />f, ' • No. of Units— ✓ Equipment Storage/Cleaning Location(s)
<br />6. ❑ PACKAGE TREATMENT PLANT For July 1, - June 30, 19
<br />' Operator Named -- -_ t"' — .- -- —_ Where Certified
<br />i;
<br />� Plant' LoCatipn, 9y's � .. � . t• — -- — �_r>> --- � —
<br />y'Plant Capacilyi—_—. , i __' _ No. Units Served
<br />mT ' I
<br />7. ElLAUNt)RY'"•For July 1, -June 30, 19 ,
<br />SIZE: ❑ Less T.han.1,000 Sq. Ft., `�t More Than 1,000 Sq. Ft. 1
<br />CI DRY CLEANING, C�berriicals Used/Amouuhl/Mo. _ % �.- -- — -- -- — — --
<br />tiomeD%v.'w c
<br />orlfc d agrht'<'Lnatul�esrttt�sthn! llowin cerlifythatInthe pr,,fo:manee ofthe work forwhich tit -is permitisIssued. Ishall To! errployany pe.
<br />such
<br />it friRt> b1h8 �;t,opGtr ML7r. Ii735pf '•1 r �Ka�iOq r cr do:roi'hngt '1 arGf, 1?I3S .a the performance of tie work for •which this permll is issued, I shall ,
<br />employ perSona ,e0,uct t0
<br />I hereby certify„that I have prepared this apNcalit>n and that the.-,or�k-will be done in accordance with San Joaquin County i •.`
<br />ordinances, state laws, a eules and rogu ions f'lhe San Joag0in*Local�Health District. _ \
<br />APPLICANT'S SIGNATURE X — - — — — f- — -- . --- — — —
<br />/
<br />r
<br />FOR DEPARTMENT USE ONLY
<br />Fee is Due: ❑ ANNUALLY ❑ PEH UNIT ❑ PER SITE ❑ EACH ❑ January 18 Hcceived By January 31 ❑ Ju1y 1 & Received lay July 31
<br />.— — -- ---r=- -- REMIT :..v
<br />BILLING REMITTANCE 5 AMOUNT DUE. CHECKED
<br />BASE F.XPI.ANATtON I DATE DArF• REMITTED
<br />_ _ Ab70UNT •
<br />—J —
<br />FEF
<br />LESS 1 .-..-_-^-�''---..,� _ —'--f••:�
<br />°PHOnATION,__j__•_..........+......
<br />PLUS
<br />PENALTY i _ /�•,
<br />OTHER — — ” - ,—. �. ' — — } /• ,. �J.�. '�.� {, r ( — —
<br />OTHER f— _— J '1 i �� 7t- — — — _ --
<br />RCcerveo by Date:. •- —Rece,pt'No Permit No. sunnce Datr. MnilCrl Uelivere
<br />- APPLICANT --RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITt$ERVICES 1601 E. HAZE LTON AVE.. P.O. Box 2009 STOCKTON, CA 95201•=
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