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} i ApplicationswillIserrocesseewnen suomulea Propertyuomplelen. nesure tosign neAppncauon. <br /> ti APPLICATION <br /> s4 v Non-Transferable, Revocable,and Suspendable-) P <br /> GE <br /> F LI copy <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> Application i hereby made to carry on businessin the junpidictional area of the.San Joaquin Local Heal h District, <br /> us Business Na a BA) n U "re Hi55�{. 'Address � <br /> eI/rtC Address <br /> GG -L'F, ,'•.443Ji- C `f <br /> Firm Partners Addresses and Telephone Numbers t;� ¢ 7'n8 elCL <br /> � " <br /> a Suslrte le a O- S`� Emergency Telephone No. <br /> - f.st�lie''3 ?4�1tii:rsi+: . , - i. ;_;_ <br /> Cgntractor. Ice ice No: %S <br /> L'Applicants Name,(Print) .J�F-�" n v r r Title �S'� t : Qate l/' 1`: <br /> Please check Applicable Category..(14),and Fill InAhe Required Information ry0i,.t0*3' <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r <br /> For Jul <br /> '=June-.30;::19: Disposal Sites <br /> k :Description(Make/Yr., Color) <br /> Sepal No` 'r �' CAL. License No. CAL:-Lidense Renewal No.+ 1' = <br /> Gapacity *� Y -= i Gal:,Weights &Measures No. i f <br /> Equipment Parking Address <br /> Pl MPER Ya4RD <br /> jFor Julj-44i LrJ0ne 30 19 r _ _77i k <br /> }No of Ve lcles Storedi I I I <br /> 0 o ChemlCal,7ollets <br /> s I. <br /> 3-' ER <br /> e754 <br /> G �..-I <br /> fiN e75 R.S. or R.C.E. No. �7/ -� <br /> "y 'R� Rev E Name I fzC 5� -' <br /> k Test Location c2(�/.5 Z-'0 0 <br /> r Test Date/Time 7_.�4�8 c-r <br /> ay SANITATION <br /> ,lob Address/ ocation <br /> Ow ie — Address <br /> ❑ $ERTj N ❑-CESSP.00L.- ❑.::LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> s _ .r <br /> PERivIANNT2 L� TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER - <br /> 6�5© CHEM 164 For July 1;-'J6ne 30, 19 <br /> Type Construction I Disposal Site I <br /> No of Units _ j Equipment Storage/Cleaning Locations) <br /> 6. © PACiCAG�'TREb�TMENT-PLANT For July 1, -June 30, 19 <br /> r , fi ' <br /> Operator IVa e <br /> Where Certified <br /> Pte„ P.larit Lo ation <br /> ;Pia to Capacityr - No. Units Served <br /> LAUNDRY TFoeJuly.1,.-June 30, .19 l <br /> SIZE0i ess khan 1,000 Sq:. Ft.,, ❑ More Than 1,000 Sq. Ft. } <br /> GLEANING,Chemicals l3sedlArriiiunt/Mo. "{ <br /> =1 hereby certify that l have prepared this application and that the work will be done in accordance with San Joaquin-CounSy <br /> ordlnances,lstate laws, and rules d gulati ns of tale San Joaquin Local Health District. <br /> �.-.J-rue <br /> A ' <br /> �APPPLICF�NT S SIGNATURE X ' <br /> a FOR DEPARTMENT USE ONLY <br /> Fed 19.1)u@ ANNUALLY PER UNIT 1:1 PER SITE 1-1 EACH ❑ January 1 &Received By'January 31' ❑ July 1 &iReceived By July 31 ; <br /> BILLING REMITTANCE $ <br /> 1 - BASE EXPLANATION AMOUNT DUE CHECKED <br /> r —. DATE DATE REMITTED <br /> 1 k. v y 4AM06NT <br /> a <br /> 3- LESS ! r <br /> 1 _PRORATION A <br /> d .Y PENALTY:-. <br /> } OTHER _ <br /> E i OTjR I t <br /> eiveQ.hy. ,{ - Date - l Receipto': - Permit No. - Issuance Date j Mailed Delivered. - I l <br /> 0 <br /> ' ,`'APPLICANT+-RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O!ao.-2009-F_STOCKTON,OA 9526V <br />