|
� 0
<br /> Applicriians Wilt Be Proca>srtd When Submitted Propels;Completed,be Ste-To Sign The Application.
<br /> APPLICATION ;5
<br /> (Por Non-Transterable,Revocable,and S%igxmdabte)
<br /> SI:r T,A.c'r
<br /> ENVIPONMENTAL HEALTH PERMIT s
<br /> UQUTA WASTE k.
<br /> Ap'pl natio/f]�is h/erby de carry sin Ih6 juri90+Ctional area 0f the San J in L I Real Dist t
<br /> a 43USIt1P5S Na I3A)..-!e,/El--. � - — _ Add Ss �.. r b
<br /> Owner . n `L --C�r -- , _ _ __ Address 2(W!/ _
<br /> Firm Partners,Addresses and T r hot Numbers -
<br /> Business Telep.+one Na,...:V F_-.j_s"� ..____.._..,r..._.. Emergency Telephone
<br /> Contractor Lloence No.
<br /> Applicants Neme;Prinl �C�_._ � Title
<br /> Please check Applicable Category;1-7)and FNI In tM Requhsd Inftfrmaffen {A-I
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) F"
<br /> For July 1, June 30. 19 _ - Disposal Sites
<br /> Description(Make/Yr.,Color)..
<br /> Serial No CAI..License No. CAL L}oe m Renewal No.
<br /> 1
<br /> Capacity tl _-- Gel_Weights 8 Measures No.
<br /> Equipment Parking Address
<br /> 2. ❑ PUMPER YARD
<br /> For July 1 -- June 30. 19 -- -- + K
<br /> No.of V,whick$Stored
<br /> No.of Chemical Tollets Stored
<br /> 3 ❑ PERC&ATION TEST
<br /> R.S.or R.C.E.Narita_ R.S.or R.C.E.No. �-
<br /> Test Lo ation _ Test Dale/Time_—
<br /> A. EYSANITATION PERMIT3 3 7 y
<br /> "Jab AddnmWL on
<br /> Owner d.e [!di>L[�cl�!r_ Address
<br /> }G/'•t�SEPTIC.TANK ESSPOOL (ACHING FIELD &SEEPAGE PIT © PACKAGE LANT
<br /> D�ERMANENT TEMPORARY G3-KEW 13 REPAIR ❑ OTHER
<br /> 5. © CHEMICAL TOILETS For July 1,-June 30. 19_—
<br /> Type Construction __ _Disposal Site _— -- ---1
<br /> No.o1 Units Equipment Storage/Cleaning Location($)
<br /> ,
<br /> & ❑ PACKAGE TREATMENT PLANT .For July 1,-June 30, 19
<br /> _ Where Cettifitld -- --- -
<br /> Operator Name".� _-•_-----—' ..-- r
<br /> Plant Location
<br /> n ,
<br /> Plant Capacity ----'No.Units Served w ., _�_ •
<br /> 7. O LAuiA m For July 1,-June 30. 19 -- - -- -- - F
<br /> SIZE:' ❑ Less Then 1,000 Sq.Ft., ❑ More Than 1,000 Sq.Ft.
<br /> © DRY CLEANING,Chemicals Used/Amount/Mo.
<br /> �.
<br /> Nemeuawre.erNeeerredageM'reigns!ren►MrtiTr.erhetoRawlnp:'lreKf�h}.••a �ti.-aarr^+�w-�r•��.rwerlr'.a�alirhlh�Sper,+'ItielSspCR.teAatlrlotC„1AIbYa�iMfsen
<br /> In such man as t:betomc suwo to work�;^'y co"risavion IxvIs of C:d:!Mr I ,
<br /> Cel,raaclar'r liking er sllr,•C{m:�AG1ing .,gm,eeirs cerlirine•the tollavvinw i rrrltly'I al Ir ihr b,the work far which this mffdt h lssued,I Malt
<br /> elrlpley g11rSella aUuJlCI 10 fy4rynl,:7;GQ^r,C ilsa',r111 i;tk t u1 Caiiicrnib." i �''
<br /> r ('hereby certify that I have prepared'Thl and that the work will be done in accordance Reith San Joaquin County
<br /> t?rdirtBnCes,state la s ru n e San Joaquin Local Health District, 1.
<br /> APPLICANT'S SiGNATUR
<br /> Y a: ftp,
<br /> FOR DEPARTMENT USE ONLY
<br /> Fee Is Dile.D ANNUALLY ©PER UNIT D PER SITE ❑EACM D jx-_s v t d R.crir_ed By Januilry 31 D July 18 Recliw4 By July 30_-
<br /> �. - RE
<br /> 'dACE I EXPLANATION DATE DATE BILLING REMITTANCE-^� REMITTED S AMOUNT DUE CHECKED
<br /> .�.r.._�—.--- .—..._�.. ..-I ._.•._�._..._,.__�. .—..._..__._--'- --._.._._.-....,_..... ,rte------" ''�.�
<br /> - -
<br /> FEE
<br /> LPRQRATIDN
<br /> PLUS
<br /> PENALTY.-.Y..., ...-.......-. __. � -...._.-_...... _—....._ -»-...--..-• --�-- •-- -.....,r.....,.�_ - J -._ -
<br /> gTMER
<br /> "Oonco D�T�--..-,.... �....w.;...
<br /> - AMMAN?_neTUMN ALL c6mfa rn RkwooMYRM7AL HlALIM hrMMIT/89mri IS seat I-MA=ELTON AVl 0.O,ser Nft STOC11TMCA Matt "
<br /> - -_ � �,I^,� 'jti'„�3 ilia .�� '�.ft ff •�±,7� "
<br /> L—-
<br />
|