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2k <br /> Appffcallons Will Be Processed When Submitted Property Completed 8e Sure To Sign The Application. <br /> APPLICATION <br /> . µ � <br /> a (For,Non-Transferable:Revocsdle,ana!5uspendabte) . <br /> ENVIRONMENTAL141EALTI4 PERMI1` SEPtJ4GE � <br /> a <br /> tIQUID WASTE <br /> Appllcati is h eb ade to Far o buaineSS to th uflSdtcfionaE area of the fan J quin total}(eafth D- 1ptrict <br /> ,q f3usin�ess Hartle[RSA7 �- <br /> 's <br /> Address -_---- - <br /> .y <br /> i'clan Partners AddressL and Tel ne �b rs g enl:y <br /> Telephone No. <br /> �Business Telephone No; Emer <br /> Copitracior LiCertce No s - Date <br /> ApptiCan;s 0.{Print): s �_'' �1 ----k Tlve <br /> Please eheck'.Appficable.Category(7-7)and Fill,in the Required Information yK <br /> 1 ❑ PUMPER VEH1CLE PERMIT REGISTRATION(FOR EACm VEHICLE) <br /> For Juiy I. June 30 19 Disposal Sites <br /> Description(Meke/Yr COIor), .-. <br /> aerial Np ��._...— CAL.License No. __ CAL.License Renewal No. ._ .. <br /> ;F <br /> Gal..Weights&Measures <br /> (kms <br /> Equipment Parking Address - y <br /> z ❑ PUMPER YARD, - € <br /> For July t June 30.19 '-7 - <br /> No:of Vehides Stored .. <br /> No_of Chemical Tottets Stored, - <br /> ` ❑,PERCOLATIONTEST <br /> R S"or fi.0 f✓Name '.. la.S.or:A.C.E;No:, ` <br /> Ter! ocati0t.,. _ Test DatelTime.. - <br /> A. If SANITATION PERMIT . <br /> Joo AJdr ocati. ' -,. <br /> Owner ` Address l&f --- — -- - Y <br /> ❑SEPTIC TANK ❑ CESSPOOL litCFtfNG FIELD SEEPAGE Pit ❑ PACKAGE PLANT ?. <br /> ❑ OTHER <br /> ❑ P>=RNIANENT 0TEMPORARY ❑ NEW �('FiEPA1R <br /> SO ❑ CHEMICAL TQII ET$ For July 1,-.June 30.18 <br /> Type don3tructipn Disposal Site — <br /> NO-of Units. <br /> Equipment Storage/Cleaning Location(s) <br /> 6.,❑ PACKAGE TREATMENT PLANT 'For July. 1.-Junc 30,19 <br /> operator Name _ Where Certified <br /> Plant Location, Served <br /> No,Units ed <br /> Plant Capacity <br /> 7. ,❑ UIaNDRY for July 1.-June 30.19 <br /> SIZE:- ❑ Less.Than 7.000 Sq-FIT. ❑ More Than 1.000 Sq.Ft. <br /> 'x <br /> ❑ DRY CLEANING.dhemicals Used/Amount/Mo. <br /> x <br /> E-hereby certify that I have prepared this a piication and that the work.will be done in accordance with San Joaquin County' <br /> ordinances,state laws:,and r es and r ul tions i 1 e San In Local Health District. <br /> APPLICANTS SIGNATURE X <br /> x <br /> r <br /> FOR DEPARTMENT USE.ONLY . <br /> Fee Is Due:❑ ANNUALLY ❑PER UNIT ❑ PER SITE -❑.EACH- ©-January.I t.P:ce+ved By January 31 ❑July 1 6'Received Ey July 31 r E <br /> _ <br /> - —� _- —REMIT <br /> y BILLING REMITTANCE AMOUNTDUE CHECKED <br /> BASE EXPLANATION DATE DATE r. <br /> _ <br /> AMOUN:' r <br /> FEE C <br /> na ppppATION <br /> PLus <br /> PENALTY _ <br /> . .OTHER <br /> OTHER <br /> f ( S 1 t-q If�'�C +f�/r v�Vv <br /> Rccetvetl—'py'_...... Date.- - RecCP[No. _l 1 S�L(�.U L!I T'e ;Y - <br /> _ Peen l NO t Isswiiiii�ccce Dale Mailed Del###grad y4 <br /> ~ '�AppLICAFrT�RF{UrtN ALL COPIES TU_ ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE„P.O.Bax 5009 3TOCRTON,GA 95501.—�- <br />