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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable,Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application ishereby made to carry on business in the j urisdlctional area of the san Joaquin Local Health District <br /> sinless Name (DBA)'f2_/l.tOgt�o���T c_ . I '--� 1�—._._ Address_f.O..Bic L'jMq_1��1 <br /> 4 *net--_ _ _ — _ -- _ _ _ Address_ _ <br /> Firm Partners.Addresses and Telephone Numbers _ ___ — — <br /> iBusiness Telephone No. —.._ �=q{pg�—____ Emergency Telephone No. _ <br /> i Contractor Licence No. ___7,V* —_Sqg_ _ c2� _.—. <br /> _Applicants Name(Print) S�T�4a-1 • {�S♦M� _ _ Title L7ss --- — <br /> Please check Applicable Cate A4eT62 — Date <br /> PP Category (1-7)and FIN in the Required Intomfa join ((y� <br /> I. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) VU <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 a Meesuree <br /> Equipment Parking Address - <br /> 2 ❑ PUMPER YARD --- <br /> For July 1,_— June 30, 19 — <br /> No of Vehicles Stored <br /> No. of Chemical Toilets Storeo <br /> 9. 11 PERCOLATION TEST -- -------- -- <br /> R.S. or R.C.E.Name _ R.S. or R.C.E.No. <br /> - _ <br /> Test Location _ Test Date/Time ( <br /> 4. &'SANITATION PERMIT ,. `` ---- — -- -- <br /> Job Address/Location �S`SQ�_ N. >QLS1011)=LD <br /> 0 I <br /> Owner��> 1Gi1Q5Address—� --- — - ---�5 <br /> 1❑�,.S�EPTIC TANK ❑ CESSPOOLLEA �— <br /> PERMANENT ❑ TEMPORARY O NEW �(��EPAIR car Q PACKAGE PLANT <br /> r� REPAIR 13 OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19__— <br /> 'Oe Construction_.__ Disposal Site <br /> of Units __ — — — Equipment --- <br /> '�. — -June — ___ __— —lCleenirtg Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,,-Jura 30, 19_— _ <br /> Operator Name=__—_— —_ _—_—_ —_——-- __ _ Where Certifbd <br /> Plant Location — <br /> Plant Capacity NO. Ut1itS Served <br /> 7. 13 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/Amouni/Mo. _ <br /> 1 <br /> I hereby certify that I have prepared this appliclaijkon and t t the work will be done in accordance frith fan Joaquin County <br /> ordinances, state laws, nd rules an gulations the Sa oaquin Local Health District. !t <br /> APPLICANT'S SIGNATURE X ---���— <br /> FOR DEPARTMENT USE ONLY i <br /> FN Is Dust-❑ ANNUALLY ❑ PER UNIT ❑PER SITE ❑EACH ❑:Janus I A Hecei.ed a January 31 <br /> T r7yT� Y rY ❑ Jury 1 &Received By July Jt <br /> —BASE "PLANATION �LLtMN �R9in NOE •1~ y REMIT <br /> ANIOUNT DUE CHECKED <br /> —_ -- � — — --I- <br /> DATE < oA _I_REMITT(D AMOUNT <br /> FEE --- -- <br /> LESS <br /> PRORATION --- ---.— <br /> PENALTY ---�-- ---- <br /> OTHER <br /> --gy�pp �=Sft <br /> � 1�6 <br /> ReCeivM M ——.Dale ---Reeaiat NC. rmit No. Imuance�a <br /> MVLN:ANT—R MI ALL COPIES TO, ENwRONNENTAL HEALTH PEi1MITISEWICES Deevared <br /> 1601 E HAZELTON STOCKTON.CA NMI <br />