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3- <br /> 41 <br /> Applications Will 130 Processed When Submitted Properly Completed.tit Sun To Sign The Appikatton. k <br /> APPLICATION t <br /> (For#Ion-Transfen6W.Revocable,and SueatAdable) �l �TAG� <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE f <br /> Application ijhereby made to carry on business in theu ' dictional area of the San Joaquin Local Health " trict <br /> hBusiness Name(013A) Address..�.1��: �E 7 f��• — <br /> 0w'ner.--....,.... _` Address <br /> Firm Partners,Adtlrees an Telephone Num elf rs <br /> Ss -- <br /> Business Telepho. �r/�'+r Emergency Telephone No.— <br /> Contractor Licence No. ?i _ <br /> { Applicants Name(Print) ___L c ___ Title — te -- Date <br /> Phase dlm*Applkable Category('1-7)and Fill M tin Requlhd Information !r <br /> { 1. ❑ PiJi kR VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) I, <br /> i For July 1.. . Jut►e,30,19 Disposal Sites <br /> 1 <br /> De`scripNnn'(Make/Yr.,Color}� ..�_ � ---•-'-- .���._ M.,... <br /> terlal No. I CAL.License No. --•--- CAL.Lior.lse Renewal No. <br /> CaP*dN Gal.,Weights 8 Measures No. <br /> V. <br /> Equlpmeht'Park"Address ��-- <br /> L ❑ kmm YARD <br />' For July 1, :lune 30,10 <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored <br /> A A ❑ Pacot ATION TEST — <br /> A.&at KC,E,tame . ' R.S.or R.C.E.No. <br /> Teat LL tion Test Date/Time <br /> 4. Ilf SANY1'ATION PERMIT cL <br /> Job Add tion <br /> Owner — Aiferess <br /> MISEPTIC TANK 13'CESSPOOL 191,EACHING FIELD &Z EPAGE PIT © PACKAGE PLANT <br /> WPERMANENT ❑ TEMPORARY tf!'NEW ❑ REPAIR ❑ OTHER h <br /> S ❑ CHEMICAL TOILETS For July 1,-,Jure 30,19 <br /> Type Construction _ Disposal Site _ <br /> Nv,of units _ Equipment Storage'Cleaning Location(s) <br /> 6. 0 PACKAGE TREATMENT PLANT For July 1.-June 30. 19 <br /> Operator No" - — Where Certified _- £ <br /> Plant Location _ <br /> _ f <br /> Plane Caps�tiy `� _ No.Units Barred <br /> 7. ❑ LAUNDRY For July'1,-June 30.:9 — <br /> SIZE: ❑ tress Than 1,000 Sq.FL. ❑ More Then 1.000 Sq.Ft. <br /> ©DRY CLEANING.Chemicals USed/Amounvmo. _ <br /> S <br /> I here certify that 1 Crave <br />� by y prepared this api:+lkaticm and that the work will be done in accordance with San Joaquin County <br /> ordinances.state laws and rules andiftulations Of the So uin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR 0EPART11101ESIT USE ONLY <br /> Fre b Due:CI ANNUALLY O PER UNIT V PER SITE_ Q$ACH ❑JAnumv 18 Raoened By January 71 ❑July I a Received By July 31 <br /> `BILLit10 REMITTANCE S REMfT <br /> - BASE EXPt.ANAT1pN iAMOUNT DUE CHECKED+' DATE DATE R£M17T£D __�t AMOUNT <br /> rEE —_.1....- ._.....�. ..__...._...--- <br /> Liggg <br /> PPEENNAALTV � <br /> OTHER — - " ......�� _ ..._,......_.._ ...,_.....-._..- ---....... .. <br /> Aoce+rrN <br /> , o OirmfNO <br /> - I . Fen �lcd 6ble / <br /> L �� r' <br /> -Ma�1ed -�elV,rerlp�� <br /> -.--. APPLICAM-16TUIlk ALL cOP1Es TO: ENV*OK1MENTAL HEALTH PERMIT+SFAVIC[S taol E.HAYELTON AVE.,P.O.see 26M STOCKfON.CA re201 <br />�1 <br />