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_ om <br /> y r � ppplicatlons Will Be Processed When Submitted Properly <br />� J APPLICAT ION S�pjgGE <br /> (For Non-Transter8ble,�Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH <br /> TH PERMIT <br /> LIQUID WASTE <br /> aqu' cal Health istrict <br /> iy ma a to c rry on sines i e fur fictional area of the T <br /> Applic is herepy Address ; <br /> H Busi s me (DB Address <br /> d Ow r <br /> U Firm Partners, Addresses and Telephone Nu Emergency Telephone:No. <br /> J _ --- - <br /> 0. Business Telephone No. <br /> Contractor Licence No. • - <br /> Title Data <br /> c.. h <br /> a Applicants Name(Print) red,lntormation I <br /> a.;' licable Cate o (1-7)-and Fill.in,the R <br /> Please illi k App <br /> ❑ PWAP.I`R VEHICLE PERMIT,,REGISTRATION (FOR EACH VEHICLE) - <br /> 1 :.mss _ = — —Disposal Sites' + <br /> Fo'r July,, a Jurfe 3� 19 <br /> CAL. License Renewal o. <br /> Descrlptioh.(fdlakelYr.>,Co or) CAL. License No. <br /> Serial No. / 4 <br /> Gal.,Weights&Measures No. <br /> Capacity <br /> t <br /> Equipment Parking Address E -4 <br /> 2, ❑ PUMPER YARD 0 <br /> For July 1, June'30, 19 '' a t r� <br /> f. i. x�_.s t # <br /> No. of Vehicles Stored ti - W - <br /> No. of Chemical Toilets <br /> r- --3:"❑-PERCOtATION'TEST"" {""'""` <br /> i R.S. or R.C.E. No. <br /> r R.S.or R.C.E. Name Test Date/Time r " <br /> s <br /> Test L ation a I +� <br /> q• SANITATION'PERMI <br /> e <br /> Job Addr s/Lo tion r Address <br /> Owner ❑ LEACHING FIELD SEEPAGE PIT ❑ PACKAGE PLANT u <br /> CESSPOOLEPAIR ❑ OTHER <br /> ❑ S T TANK D <br /> PERMANENT <br /> ❑ TE.MPORARY ❑ NEW <br /> g, ❑ CHEMICAL TOILETS For July 1, -June 30, 1�isposal Site <br /> } <br /> Type Construction e <br /> l Equipment Storage/Cleaning Location(s) <br /> No.of Units a 1. June 30, 19 <br /> g, ❑ PACKAGE TREATMENT PLANT For J Iy�- .�_ -- Where Certilied <br /> 's _ r <br /> Operator NametAllf <br /> Plant LocationN <br /> i o'. Units SeIry ed�`� <br /> Plant Capacity <br /> r <br /> 7.' ❑ LAUNDRY Foruly`1, -Ju 30, 19 <br /> Ft ❑ More Than 1;000 Sq. Ft. <br /> SIZE:, , ❑ Less Than 1,00p Sq: �. <br /> 7 _ <br /> 13 D r L ANING Chemicals Used/Amount/Mo. '"•C f 4 <br /> oe _or kranseatagemar+igr,turecr..t;fh+stheiotto.+nn� 'Itertifgt'xfr,e�n�.Trrmanr,P4yfthwork prrmitfslssutete^pteyarryAers­ <br /> r <br /> In such maTfner as to-bkorR,"subnt To wol:"nFr1' CORkDersai-i IaiI C,311:0_:: <br /> Corttrattos'x Kirin or Sus cont>aciN�apeMirr, c�rti're °hr.�foliov�in�+: f uc:..'. � eriDr;lanCc c'•ih,uotk lar hltich.S�is^';Iii; s t5s e�.!Shalt <br /> employ persons iu1 jattt 1QfW pY:�f311=S,�•�@�iSi.tiliCl!dltin JR v+iidc:r�;ld?�., �' � ~`"�,fv <br /> f t application and that the work will be done in accorc�ay�n�ce with San Joaquin oun y <br /> I hereby certify hat 1 have pr .', fthe San Joaquin-Local Health District. <br /> ordinances, stateaaws an rules a .r 1.r <br /> r . k <br /> �G' �. IN <br /> APPLICANT'S SIGNATtRE X i <br /> . FOR DEPARTMENT USE ONLY <br /> ed By REMIT <br /> Fee 18 Due: 0 ANNUALLY ❑.PER UNIT, PER SITE _0EACH ❑ January 1 &=R eiv$By SanuarY 31 AMOt�July I DUE &ReceiCH CHECKED <br /> 31 <br /> BILLING REMITTA'NCE ~`� AMOUNT <br /> BASE EXPLANATION DATE .» DA�T .ra 'REMITTED - <br /> FEE 014 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER- <br /> t ' <br /> ' �' .... � Iss ance D to Mailed Delivered <br /> Receipt No� Permit Na. + <br /> Received+by ' Date A 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTOto $� � <br /> 9 APPLICANT—RETURN ALL COPIES TO: ENYIRONM€NTAL HEALTH PERMITlSERYICES 1 j �Z <br />