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PLUMAS COUNTY PUBLIC HEALTH AGENCY ENVIRONMENTAL HEALTH DIVISION Quincy Office Chester Office 270 County Hospital Road, Suite 127, Quincy, CA 95971 PO Box 1194 Chester, CA 96020 Tel (530) 283-6355 FAX (530) 283-6241 Tel (530) 258-2538 FAX ([PHONE REDACTED] SEPTIC PUMPER VEHICLE APPLICATION FOR PERMIT TO OPERATE OWNER/OPERATOR INFORMATION Business Name: Owner Name: Physical Address: Street City State Zip Mailing Address: Street/PO Box City State Zip Telephone Number: FAX Number: VEHICLE INFORMATION VEHICLE #1 Make Year Color Tank Size Vehicle License No: VEHICLE #2 Make Year Color Tank Size Vehicle License No: VEHICLE #3 Make Year Color Tank Size Vehicle License No: VEHICLE #4 Make Year Color Tank Size Vehicle License No: VEHICLE #5 Make Year Color Tank Size Vehicle License No: I hereby make application for a permit to operate the above facility in accordance with the state health laws and local ordinances and regulations. I certify that the above information is true to the best of my knowledge. Date: Signed: Below For Office Use Only Date Payment Received: Amount: Receipt No: By: Date Inspected: Permit Approved By: