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� wppncauonsWIT1BeProcessedwhen SubmittedProperly Completed, BeSureTo SignTheApplication. <br /> l i APPLICATION <br /> �f Non-Transferable Revocable and Suspendabl P P GE <br /> It 4 r <br /> ENVIRONMENTAL <br /> wnsrE HEALTH,PERMIT 1 i 0 P <br /> E 4 <br /> �t Application i hereby made o carry on busine s in the juriAd Ictional area of the San Joaquin Locial Heal h-District,- 1 <br /> xr'�Businessrr� i' H55cx.'-`A' ddr'e's's'__OwnerTI <br /> " �, u rtt Address <br /> U - .' 'L•j"3. 3: y y.' cit_` _ f• t... <br /> Firm Partners,Addresses and Telephone Numbers _[ ]� <br /> n f3usl a "�(e a r^ -� Emergency Telephone No. <br /> yah <br /> �Cont�acto�Llce�e N��At3: �.�'_•_ %S - .. .l .._ ��. [ <br /> T �Appllcants Nam0. <br /> e,(Print}..at.., }'�, `"' r �. Titlef+Y?�@r�"- :` Date' <br /> Please check Ap-1kible Category.(14)-and Fill-in.the Required Information <br /> 1. ❑ PUMPER'VEHICLE,PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> F yJune_30;:19 Disposal Sites, <br /> _or Jui .�4;- <br /> z= Description(Make/Yr., Color) <br /> Serial ial No.� _ 1 ;. ,___ . _... -..__ r. <br /> t CAL. License No. CAL:Cicerise Renewal No. .�r s <br /> Capacity I Gal.,Weights & Measures No. . <br /> Equipment Parking Address <br /> ( ,2' P MP R YARD1 { <br /> ' For Jul TT June 30, 19 I I <br /> No of'Vehicles- reef - <br /> � No o C hie al-Toilets Stored <br /> 33; (<?ERC�LATIONTEST <br /> 'R.S Qr.R1;C E 1Name /L �i11 t�� e�17� R.S. or.R.C.E. No. �C /5��7/ ! # { <br /> g� � 4� l.. .. -S Test Date/Time �7 9 cz, <br /> Test Loc tion /_0__7� c !ri �^ <br /> t <br /> : .RA'WIT TION,PERMIT, <br /> Job Address/Locat!oR ' € <br /> Owner Address - <br /> © SERTC�AN ❑.CESSPOOL-. ❑_=LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ' PERMANENT 4. TEMIPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5 ; © CHEMICAL TOILETS_ For July 1, -June 30, 19 <br /> Type Construction-.` 1 Disposal Site t <br /> No.of Uhits- I Equipment Storage/Cleaning Location(s) <br /> � j ❑ PACiCAGE;TREgTMENT�PLANT For July 1, June 30, 19 <br /> e <br /> }Operator Na ke` !_ Where Certified A ` <br /> :. <br /> x " <br /> Plant Lo6atio�; � t <br /> v ;Plant Capacity No. Units Served ; <br /> Y �T.�❑ LAUNDRX_ For Juiy.],_.. June 30, 19 <br /> ,SIZE F'�,Less^Than 1.,000 Sq�_ Ft-,. ❑ More Than 1,000 Sq. Ft. <br /> r❑ QRY CLEANING Chemicals Used%Arriount/Mo. <br /> f f dere y certifythat"i have prepared'this application and that the work will be done in accordance with San Joagsuin County. <br /> ordinarlcesjsstate laws, and rules d gulati ns of the San Joaquin Local Health District. : <br /> _. <br /> `�APPLIC�NT S S GNATURE € <br /> ' FOR DEPARTMENT USE ONLY <br /> I <br /> Fe¢1Ls,Dde ❑ ANNUALLY © PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 f ❑ July 1 F.jReceived By July.31 <br /> BILGING REMITTANCE $ "REMIT` <br /> BASE EXPLANATION AMOUNT DUE CHECKED , <br /> DATE DATE REMt7TED --;AMOUNT s -- <br /> �t t I ' <br /> f <br /> LESS a <br /> .-_.S-PRORATION- <br /> PLUS <br /> { <br /> PEN ALTYf j <br /> i- <br /> 3 . <br /> OTHER <br /> 41 <br /> Jf t elved;,by k�.;i Date ;Recei o: Permit No, Issuance Date j Mailed Delivered µ } <br /> ' n ""APPLICANT—RETURN ALL,COPIES TO:- - ENVIRONMENTAL HEALTH PERMIT/sERVICEs 1601 E.HAZELTON AVE., P.O:Box 2008 ST OC CAt85201` - <br />