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Applications Will Be Processed When.Submitted Properly:Completed.Be Sure To Sign The Application. ^� <br /> APPLICATION <br /> (For Non-Transterabt-i,tteYocable,and SuSpendabl6 <br /> y 11 <br /> ENVIRONMENTAI.-HEALTH PERMIT <br /> LIQUID WASTE <br /> gSZ o� <br /> Ai}pllcatlon is hereby made to ro a business rnthe jurisdictional area of tPsOan. oaq u1n Local Heal(h District V <br /> 8uslnessName:.fl79A)Mc-?�R � �i-F �"_ Address <br /> ,- Address _ <br /> c Owner.: <br /> R-Firm Partners ,4Cdresses and?_ el' none' umbers <br /> Emergency Telephone No - -�- <br /> {Business TelephOne <br /> Contractor Licence NO. :_ - <br /> �Appiicants Name(Print). - <br /> Title .- - Date-(0=r <br /> - <br /> Please.check Applicable Category(1-1)and Fill in the Required Information <br /> 1 Q ?UMPER VEHICLE PERMIT REGISTRATION{FOR EACH YEH,iCLE) <br /> Fol JtSiy 1 .lyrie'30.zs _= Disposal Sites. <br /> s DescrijYJon(00181ce/YT..Color) <br /> . CAL.License No. [ CAL License Renewal Nv..�_- --•— <br /> Seriat No - r <br /> capacity _ Gat_.Weights R Measures No.'- <br /> Equipment Parking Address <br /> �e .. 2 tom. PUMPER YARD <br /> ForJuty 1, Jcine 3D,-19" --- <br /> -- -- - - <br /> � No.ofVehiclesStared - <br /> No.of Chemical Toilets Stored ` <br /> 3 ©=PERCOLATION TEST ; <br /> R <br /> Ri S.:or R-C-E Name S.or -o. <br /> --- - - - <br /> 9:C E-,N <br /> Test` tori: Test Te DatelTime <br /> 4. NiTATION PERMI`5�, u <br /> Job Addressrt,atailon-- <br /> S"r <br /> Owner �:i.tf?n .- Address <br /> ' c�?. <br /> ❑.SEPTIC T.ANiC ❑,CESSPOOL. :LEACHING FIELD %as SEEPAGi E PJT ❑.PACKAGE PLANT <br /> pERiut,�NENT - ❑ TEMIPORARY ❑ NEW V,REPAIR <br /> ❑ OTHER <br /> 5. '❑ CHEMICAL TGILETS For July 1.-June 3t?.1 - ^-- - ' <br /> Type Construction Disposal Site" <br /> :r <br /> N0.,of Units Equipment Storags/Clean,ng Location(S) - f• - <br /> h`5 0 PACKAGE TREATMENT PLANT 'For July 1.-June 30,18 -- -- <br /> _ Where Certftied <br /> Operator HOrne <br /> Plant Location . -- --� — - <br /> r No.Units Served <br /> Plant Capacity - - <br /> 1.11v 7: ❑ LAUNDRY For July T.-IJUne 30.19 <br /> SIZE ❑Less�han 1,000 Sq-Ft.. C3 More_Than 1,000 Sq Ft: <br /> ❑ DRY CLEANING,Chemicals Used/Amoynt/Mo = - <br /> ! tiawieownwFo.lieansedapdrYstiynxarebrwIteat�v:Iliow9ri4:-Iteislwtt«',if,tfiepe•.rcrrcarteC.ClINwork forwhfGitttisprrmftisissrrsc'.I.slsalEnot <br /> i .•ir stxh mamaras fo becMne suDjtxt to rytal•;tlae.corrpensaGor_lams n'Cdli:�in[a-1 crr[i1 thr:in the perirsri;laRta c.Lir Work tnr which thi ttrmlt is kz,.._'. .•r <br /> . C0pvsc",j la" Ot 7uR-cva!raK%v0 iryl\SIYr� Certitiei sh/rloilowln¢. Y <br /> employ peMO"*ISTect Io woncaran$cnrr AS3.+ap ta;rcrt sitalGd <br /> t . <br /> i.hereby certify that 1 JTaVC repared.this applicatlort and that.the qA wf�be dorsa in accn�dane�Kith San Joaquin County <br /> I and r ions oft n J [in aGat atth:Distri^t. `l1f <br /> # ortlinanc�,state laws. e9 -, _- -- .-- <br /> ANTS SIGNA.TURE X <br /> APPLIC <br /> FOR,DEPARTMENT USE ONLY �Y•,' <br /> i 8 Atcewed By July 31 <br /> #C Fre I!-Due.❑'A�rhrUALLY . PER UNIT. .� PEH SITE. EACTH i7 January 1 8 Aece ed a/.sa�uaF 3' ".'.W REMIT <br /> - BASE - •�. E%PIJ1MA710N '--Uj4G REMITTANCE - S - AMOUNT JUE -CHECKC0 <br /> o �' riATE DATE ,REMITTED AMOUNT <br /> - , FEE _-- <br /> Lm <br /> ! <br /> PLUS .- <br /> ' PENALTY <br /> OTHER <br /> r RE�eerr'l�DY —_ .�.-....-_._pat. —' - — mece+pi NU ._�,-....._.f Per [[�.o <br /> -issusnce a Malted -m�eliveeeC 1 <br /> APPL1CANr.:.REFURN ALL COP1E5 T6: EKYIRONIFENTAL HEALTH PERNIT;SFRVICES: 7ep7£•HAZEETOM AVE.,P.r)-eo,[200J .':fOC1fT0[V.CA 75!01 s <br />