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1 <br /> 1� <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sura To Sign The Application. <br /> APPLICATION rf <br /> (For Non-Transferable,Revocable,and Suspendable) F <br /> ENVIRONMENTAL HEALTH PERMIT SEPTAI.E ; <br /> LIQUID WASTE <br /> Applic n is h�rebr mad8 tp carry on business inithe'uric Iclional area of the an Jaa in Local Health Distr' t - <br /> Rusin am {D8A .WGJQ,�y�_ ( R_ Add ess t� �� -- - -- <br /> Owner- Address _ - -- ----- - - <br /> Firm Partners.Addresses and Telep`ho�n^e Nu ers - <br /> Business Telephone Nek �D -- Emergency Telephone No. <br /> Contractor Licence No. <br /> �Applicants Name(Prins) - � __-Title <br /> Please check Applicable wry(1-7)and Fill 1 gequlred InlormaHon <br /> 1. © PtJIiMPM VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30,19 Disposal Sites -�- --- <br /> La Description(Make/Yr..Color) -----� --_. - f <br /> Se -___-�,rial No. ICAL.Licensri No. -- --__-.� CAL.License Renewal No. <br /> i <br /> Capacity __ Gal.,weights d Measares No. - -- --I---�--- <br /> Equipment Parking Address - <br /> ;+ 2.--,❑ PUMPER YARD � <br /> F:00 July 1, -June 30.19 - -_ <br /> Nb,of Vehicles Stored - - <br /> No.of Chemicai Toilets Stored - <br /> 2ti ❑ PERCOLATION TESTrw AS.or R,C.E.Name R.S.or R.C.E.No. <br /> Testt.L�tion _ Test Date/Ti-ie <br /> a. i�SAMITATION PERM N+ _�j <br /> Job Addr tion t� di. <br /> r --..._ f . <br /> Owr►ai Addrer� <br /> ®'SEPTIC TANK ❑ CESSPOOt I EACHINO FIELD -SR"T EEPAGE IT ❑ PACKAGE PLfAN't <br /> '11th", ❑ TEMPORARY EW ❑ REPAIR ❑ OTHER ` w <br /> ❑ CHEMICAL TOp_£TS FoT July 1,- <br /> no <br /> 30,19 , <br /> 3Type'�pR Disposal site <br /> 7"��ft10:Af tklilt!.,;�,,..,�;.•:.; .•-- .-------FAulllment Stodgefpeartinq Location{si":..;.,,,�.-�z*�� ^r..:..__.,..�.�._...M._.�.,._..�.,._„-,._...._ <br /> °Q.PA_C,K402111AEl►!#M/RANT fear 4*I.•June 30, 19 <br /> �waobftiiie Name <br /> tSS ry Punt rapao#[y No.Unita Sei+ed <br /> $�4",,?D LAUNDRY 'For July 1,-June 30_19 f .� <br /> " SIDE ;; ©.Less Than 1.000 Sq,Ft., ❑ More Than 1,000 Sq.Ft. T �� —29`:DRY CLEANING.Chemicals Used/AmdunbMo. ' <br /> er©� ars x, � <br /> 1 <br /> *' .y herbWoertify'that 1 have pr "na this-application and that the wo*%*14 be done in actordance w4h San Joa4OTWCounty <br /> 7 P�• <br /> 'a ordinances,state laws and rules and gu 1brls of Me San Joaquin�Pea� lth District. <br /> a. APPLICANT S SIGNATURE +�e� <br /> FOR DEPARTMENT PILV <br /> fs�e to Due:O ANNUALLY 0 PEn UNIT or Pen SIT£ ❑EA_GH _.ry 1 A Retetved ev Jnnuery 31 (�July!d Recoi"d RV July 31 <br /> BILLINQT R ITTANCE _ REMtT <br /> BAS£ . EXPLA14ATION DATE DATE REMITTED AMOUNT RUE CHECKED <br /> .... ..�_..��AT AT ---- ._........,.._._,. —AMOUNT <br /> FEE <br /> LESS <br /> PRORATION •- -- -__ ..-......_....._..__ —...._._—.-w ._.....__ <br /> PLUS <br /> Perm" - <br /> OTHEA <br /> i OTHeR <br /> 43- <br /> N- _ Date _N.WP-.�_ <br /> --- Ela;n,i u I..wnc.�ee--Ji filed <br /> • APPLICANT-IteTuRN ALL COMto TO: ENVIRONMENTAL NtALTN IMI1MIVISRM119 101 s,NAMTON Avg.,P.D.on Jim TOC141 .CA 1 <br />