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<br /> IF
<br /> r 2 APPfk�tions wall t'Be Processed When
<br /> 8ubmltfW Property Completed Ba Sure To Sign The Appeetbn. °
<br /> APPLICATION
<br /> (Fw Non-Transferable.Retwcablej and Sllap8nd8t1l!} v; -fir hPr
<br /> r Y t ENYIRONAAEI�tTAL HEALTH PERMIT
<br /> U9 WAM
<br /> RApplication{s hereby made to carry on business in the urisdietional area of the San Jos uin L seal Health DEstrid
<br /> "Business Name`(DBA) Cr q
<br /> 4 a .Address`—dam 7 jZ/e
<br /> 'J t " Address': 4 ,
<br /> }find Partners?AtJdressea snd Tei hone Numbers r �`" '{
<br /> 8u'81rieds 7elepherle NU r'
<br /> Emergency Telephone No x t,Uk
<br /> Applicants Narrre(Print) `
<br /> Title
<br /> y, Ptaase_elNeJt><ppika6le Category(f-7)and Flll In the uhed InfommMon
<br /> PIliIRPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE} d� �{�,
<br /> 44
<br /> �ForJuly,1 } June 3C i8 Disposal Sites' ,f�
<br /> D acslpNon(Ma'ke/Yr L;olmy
<br /> or)
<br /> rSe`al +Ib' *`mow k CAL License No CAL:License fienewal No :. s '
<br /> (dal'Weights 8 M
<br /> assures NO.—
<br /> t=quipment Parkiiig Address t„ �� Yw '
<br /> s. L .pu�Ep YMD sY s
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<br /> .G+"- �^ ! 115 j.y;'�' '•y
<br /> or u! �x une30419 "a,� 1
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<br /> �u�a r-�� olleta 5toredr ,
<br /> COLATION TR�
<br /> a.r r i roll v� iA
<br /> ii 8�orH`ii G EN fi s _ d.S.or R E No. , tires ' f,
<br /> Teat Da
<br /> MAN ri r ` •`lr , _ C:f r >r'4 j:�'
<br /> �' ITA710ii1-MAF11Tr
<br /> /1 f�Q�RJ�� 4,' �A•l.'�"(' F :,LS^',Y
<br /> r�eation �r_!� _ DsDD� d'.ES.
<br /> S�EPrICTANK �,CESSPOOL ,f ,LEACHING FIELD O SEEPAGE PIT ❑ PACKAGE PLANT
<br /> (FERMAI+lENT ��TEMPORARY E NEW+
<br /> s +, 0 REPAIR O pTHERt..
<br /> � f.'ilE#AICAC�TOILETB,�For July 1 June 30 19 r s•s GYM
<br /> :CorlahuCtlon`•"a:y', . �"r r•""sf, - ,.� -�i Da91 Site .f Y""`Ta,� } `• .
<br /> exUn_i ivy rtCY+ 3 rh Equipment 5torepe/Cleaning LOCation(a)
<br /> Ln-
<br /> V-13�PACKAQ!-TRLTMENT PLAINT For July,1%J6 n-i
<br /> 30 79
<br /> r r _
<br /> ��w.;;,�y �"
<br /> tL v 4 a
<br /> NO UnItS Served `,.rYry1� w.
<br /> fiLAUNdRY 'Eotr°July F"June
<br /> .IZE "� fess Than !000 F r a DFt.
<br /> Than 1000 Sq:
<br /> d b9Y{CLEANING:ChemEcala tlssd/AmountlMa
<br /> ` r `EL�r-
<br /> ! r ( •�'. 9v �' .Ar i�` r s °'' S' 1 '�-h`vs�+ �..
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<br /> �. r� +r �.a 3/:' � i S � '. F• -w a '1 a,rii.Sh+"F".w�s��r9 I.
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<br /> tie i _;
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<br /> I llereb eartify thal l have pre".Ul th:..:pplica_tion and that the work will be done In secor&W�e with SsW J '61W County '
<br /> ordinances awte laws ano-rules antl' ti a of the San Joaquin Local Health District I yc 1 r
<br /> FApPCICANT'S SIO!IATURE X
<br /> _cwT'Y'+ i
<br /> � •:' r-it,t s {til -' � �>u ''rye
<br /> K G rF"+C:i'r�'{� J"iw;•tr f°'.Y��'�. ti °i
<br /> s` }�ti� q FOR DEPARTMENT USE ONLY
<br /> FK tf aW O ANNUALLY OPER UNIT i O PER SITE. EACH 0 Janes 1 8 pKeirfd 8 Janes 31
<br /> *'"-�,-� - '!' Y N - ❑July 1 8 Racaiwd By.July:ft On
<br /> -
<br /> * EXPt.ANATIOrI BILLINfi REMITTANCE _�_ .
<br /> rt + tti '' S,w r y% zz DATE , -REMIAMDUNTDUE'-
<br /> DATE _CHECKED '
<br /> F, AMDUFfTuE.u•
<br /> FEE@g,' / Tu•„ a i
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