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+K <br /> T,� ". • `_c fb- 4 �, 4 -P Y, :� f- ,:• <br /> l -- "rya ,� 'hf; Y <br /> i. pp ie ations VI/Ill Be Processed When 5ubmltied Property Completed Be Sure To Sign The Application s <br /> 5 (For Non Transfenbhr Rerncable snd.Suspendabte) <br /> ENVIRONMENTAL HEALTH PERMITk <br /> LIQUID WASTE <br /> ADplTcalion.is hereby made to ca o Cosiness n the liinsdlztrorial area Oft San oaquin'Local Heallh District <br /> ,a Busirie55 Name IDSA} I���i�ep-x j� f. [- ? Address _ " _* �.�� 2:�SZO�y� <br /> Owner _ Address a <br /> v Firm -art, ners Addresses Arid Tele hone Numper5; s " zs F t <br /> Business Tetephone NoEmergency Telephone No. <br /> I Contractor Licenze No 7 +_ ��'�,: / '. , <br /> LLAppLcants ttarffe(Print).. {_ � Tills <br /> Ilse <br /> check Appllcabte Category(7 7)and Flit in the Required tntnrrtatlon r wry" <br /> 1. ❑ 2UMPER VEHICLE PER REGFSTRATtON(FOR EACH VE1i1CLE) <br /> J <br /> f I For'July 1 June 30 19. Dlsposai Sitea <br /> Oescrip ion(Make/Yr. Color) <br /> 5enal No. CAI.License Na ` M —` CAL Llcensa Renewal Na � <br /> {e <br /> Capacity _ Gal ,Weights&Measures Na s . <br /> Equiament Parking Address <br /> u 2 PUMPER YARD. tIr <br /> For.July 1 June 30.19 <br /> No.0f-VehiCleS Stored" _ � ; <br /> ��.. <br /> No.Of Chemical toile V; <br /> F' � a � E <br /> 3. O PERCOLATION TEST �. <br /> R:S_or R_C.E.Meme 4' ?9.S or R:C.E No. `w ` <br /> lest tion — Test DatelTime _ _ ¢ . <br /> 7 r <br /> 77 <br /> 4. SANITATlON PERM t5 <br /> Uy <br /> # Job'Address`Locaiion�L/�to 4 /.{» <br /> OwnerAddre{S�S'' -��� r4�.,� <br /> 0 SEPTIC TANK O.CESSPOOL 63-LEACHING FIEEb AZEEPAGE PIT ❑ PACKAGE PLANT, x `� 9r <br /> PERMANENT ❑ <br /> TEMPORARY::, NEW ti= } REPAIR' ❑ OTHER <br /> 5 ❑ V. <br /> CHEMICAL TG' For July 1 June 30'19 _ y <br /> ' . <br /> .Type Construction Qisposef Site _ <br /> No.of UnitsEquipment Storag !Cleaning <br /> .' 8 ❑ PACKAGE TREATMENT PLANT. 'For July 1:-June 30 14 <br /> Operator Ptame _ Where Certlfiec <br /> PlantLceatrOa` <br /> Plant Capacity N0 Units Served <br /> 7. ❑.LAUNDRY For July 1 June x0.`18 t ` <br /> g SIZE: ,'Less i-bin 1.000 S4_ft.. ❑ More Than 1.000 Sq Ff 'J <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo:_ <br /> - HoewownerrorTleeraedparit'sttiyrconed.eifirseAe'fcllowlny:,'E[errt'w h? lith p 'G: orklot wliVj1hisvrrmiiisissusr IS...linot <br /> Ir such manm,as to tvirne-su4erl to wDIP, jn S Compensalor to-'S A o- <br /> l`oMrAckr's bhin7 ar-suD epn!raeTierg srpn ttun arta.es tA�rioapyi�ng,..- :l ceflily Iha,in the Perl�ri:Tancu G...1c werh for which Ihi.zcrlr.'i i;,i <br /> - t'I1p41y PCMDR5$W*CI t0'''WorKTlan 5 COmpeLiSlIiUµld'."61It NfRor <br /> 1 hereby certify that`! have repared lhis apple atiod and that the yygrk wi he done in acro=dance Kith San .loaqum County <br /> ordinances stare laws, t and reg ions oC t r.J un oGal. Wth District, <br /> 70- <br /> APPLICANTS SIGNATURE X 6L��� <br /> V1 <br /> - <br /> fOR,DEPARTMENT USE ONLY . <br /> Fre is Duey.b AUNUA_LLY ❑PER UNIT ❑PEN SITE ❑EACH LSI January t 8 ReC!ivea 91.;a Bary 1• L] .+y i d Rxeived By JuN.31 <br /> REMIT- <br /> BASE Ex%JLNATION -titTNC REM,TTAN;E $ �.AMOUNT,)UE CHEC[f] r <br /> DArE 14E101TTED.. <br /> FEE I — � - ' <br /> LESS .. _ -I - 3 it '✓ f. –:.I- - —— x + ;_ <br /> PPURATSON <br /> PLtiS <br /> PENAL;Y,• <br /> OTHER • I. _ . _ : <br /> i r <br /> �n <br /> si+-cr.�r�pry DaI. Rece.cl Nc. .fie.m.e e:p - �Uuan[e�)a:e, Mailed l>lnre ed — <br /> -3 APPLICANT—RETtIFINALL COPIES TO: `Er1VIROHMLHTAL HEALTH P£4161I VSFRViCES IEDI E.HAZELTOK AVE..T'a.Doll 2009 .roCKTON.CA'H761 <br /> k <br /> j <br /> I <br />