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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. - <br /> APPLICATIQN <br /> -moi 3 /-N -,�' G. <br /> (For Non-Transferable, Revocable and,Su's-endable)s�. .' � 5»t <br /> ENVIRONMENTAL HEALTH PERMIT S�PTA�E' " <br /> LIQUID WASTE C; fs' •►- <br /> Application is hereby made to carry on business in the jurisdictional area of the.San Joaquin Local Health District <br /> Business Name,(DBA) V.A.R&!!R ISP � S014%_�&12G -'Address QRCz( I S4'k-0 .. ST'1Ci�1 qS;,zn I <br /> aOwner_ - Address <br /> Firm Partners, Addresses and Telephone Numbers <br /> aBusiness Telephone No. 11449-1;14�1 Emergency Telephone No. <br /> J Contractor Licence No. - "ZS <br /> Applicants Name (Print) Titl Date <br /> Please check Applicable Category(1-7) and-Fill in the Required Information,t= <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, - June 30,-19 i =` _ =-Disposal Sites <br /> Description(Make/Yr., Color) <br /> ,.--�,..N o—_-.....,.--,. ,_..- a_ -_L- _. - <br /> Serial No. t � ----� CAL. License No. CAL. License Renewal-No. <br /> Capacity' Gal;`Weights & Measures No.- - t <br /> Equipment Parking Address 1 <br /> 2. ❑ PUMPER YARDFor July 1, - June 30, 19 � <br /> No. of Vehicles Stored } <br /> No. of Chemical Toilets Stored �' r <br /> 3. ❑ PERCOLATION TEST=­­ ,�lw- ^, <br /> R.S. or R.C.E.'Name -5 R.S. or R.C.E fiNo- <br /> Testt LoWtion _ Test Date/Time.—t � � <br /> 4. �i SANITATION PERMIT r �,, {J <br /> _ ..Job Address/Location 4 !B 524 ,.&) '��,_MCF0 • � 1 KFC./. <br /> Owner a—vA Address _ \ <br /> 3 PTIC TANK 13 LEACHING FIELD - ❑, SSEEEP"GE PIT..._, PACKAGE PLANT <br /> SE <br /> 3 PERMANENT 13 TEMPORARY 11 NEW ( REPAIR „?,OTHER t.�x ; �U IA IP- <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 { <br /> Type Construction Disposal Site <br /> No. of UnitsI ; Egl.lipnten;Storage/Cleaning Location(s) 1 <br /> 6. 11 PACKAGE TREATMENT,PLANTT For July 1 --June 30 19 f , <br /> Operator Namef """' - Where'Certified <br /> Plant Location L <br /> Plant Capacity No. Units Served} 1 <br /> 7. ❑ LAUNDRY For'July 1, -June 30, 19 = <br /> SIZE: ❑ Less Than.1,000 Sq.�Ft- T11-Mre,T�anl1,;000Sq;s IV # { y{v; s; <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby ce tify that I e prepared thf' applicati nd that work will be done in accordance with San Joaquin County <br /> ordinances, state law a d les ander ulations' a San=* Health District. <br /> 4 - . : <br /> APPLICANT'S SIGNATURE <br /> Y <br /> FOR DEPARTMENT USE ONLY € t <br /> Fee Is Due: 0,A NNUALLY ❑ PER UNIT 11 PER SITE 11 EACH• 11 Jan- 1 &ReceivL_A_y-,Jarlu ary 31 ❑ JOY 1 &Received By July31_ ._ �... .._.—,�»..�:.,.._.,,� 4j,. <br /> REMIT <br /> _LiRi _.BASE EXPLANATION ILLING REMITTANCE '$ MOUNT UE CHECKEDDATE DATE REMITr .AMOUNT <br /> FEE R 4- <br /> LESS LESS <br /> PRORATION .r4�.ew .r-.ta <br /> 6. d <br /> PLUS t <br /> PENALTY l t <br /> OTHER E. f_ _ - - i. - L <br /> # k f <br /> .. _ <br /> e <br /> r„ a..OTHER':-..7...®we— <br /> ReO <br /> ceived by Date Receipt No; Permit No. IsssuXXti Date Mailed Delivered' i <br /> APPLICANT—RETURN ALL COPIES TO: ENV1 NMENTAL HEALTH PERMIT/SERVICES 1601 H ELTON AVE.,P.O.Box 2009 ST CKTON,CA 95201 r <br />