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-- APPLICATION <br /> (Fa. 4on-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicat is riereb a to ca on business in the jurisdictional area of the San Joaquin al Hea D.4 ci <br /> Y <br /> less ame [ 88/��)/���- `C-,r-c� A_ddress � / / {,K,� <br /> l:er '�Ly,-r Address <br /> Partners. Addresses and Telephone Numbers <br /> less Telephone No. c7e'6 S — enc Emer Telephone No <br /> actor Licence No. Emergency <br /> p <br /> scants Name (Print) �� f_c TitleDate J f <br /> _ <br /> se check Applicable Category (1-7) and Fill in the Require Information r <br /> 7 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> July 1. .June 30, 19 Disposal Sites _ <br /> iption(Make/Yr., Color) <br /> No. CAL. License No. <br /> CAL- License Renewal Nq. _ <br /> :city Gal., Weights & Measures No. -- -- <br /> oment Parking Address <br /> PUMPER YARD ► <br /> DIY 1. June 30, 19 <br /> f Vehicles Stored <br /> Chemical Toilets Stored <br /> PERCOLATION TEST <br /> R.C.E. Name R.S. or R-C-E. No. <br /> )cation Test Date/Time <br /> SANITATION PERMIT <br /> . es LocationL:•r <br /> ' Z"/" <br /> Address <br /> 'TIC TANK ❑ CESSPOOL <br /> LEACHING F3ELD SEEPAGE PIT © PACKAGE PLANT <br /> IMANENT 13 TEMPORARY 13 NEW REPAIR © OTHER a <br /> CHEMICAL TOILETS For July 1, -June 30. 19 446. <br /> ,onstruction Disposal Site <br /> Jnits Equipment Storage/Cleaning Location(s) <br /> PACKAGE TREATMENT PLANT For July 1,-June 30, 19 : <br /> �r Name Where Certified <br /> )Cation <br /> apacity No. Units Served <br /> '.AUNDRY For July 1, -June 30, 19 <br /> ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> CLEANING, Chemicals Used/Amount/Mo. <br /> M <br /> I hereby certify that I hue-pr+paed this application and that the work will 13e done in accordance with San Joaquin County • <br /> ordinances, state laws and rulsi&afiq regulations of San Joa in Local Health District. <br /> ANT'S SIGNATURE X •LGA i <br /> FOR DEPARTMENT USE ONLY <br /> re Is Due: ❑ ANNUALLY ❑ PER UNIT PER SITE ❑ EACH ❑ January 1&Received By January 31 ❑ July t &Received By July 31 <br /> BASE EXPta4NATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED CUNT DUE CHECKED <br /> ` � r <br /> AMOUNT <br /> ORATION <br /> Us <br /> MALTY ` <br /> SER <br /> G� <br /> -HER <br /> eewee by Date Receipt No. Permit No <br />