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b.� <br /> ^, APpflC.11 n9 Wal Be Processed Wt a Submftled Property Completed.Be hue to Sign The Appllcalloa. <br /> APPLICATION <br /> (For Non•Trstw ferabla,Revocable,and Suspandable) SE►TAZiE . <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> A,rpcati°°��Lisne�eo)��^I��adOlO CerJ/yy onD s in the{{'yydedichonall area ofln�..c�1n uioL 1 M� rnl�s <br /> W Rlglness Name (OBA) _(S,leJit_C:LJl _ N�j.. 4*4—�Addren-7- t Afs►_OS _Ve 9sZd_ <br /> Y <br /> Firm Partners,Addresses ands 3TTT�ej ho^�NJmDen_ <br /> B.Isuxas Telephone No. 1"fa-P Z_fjP ___Emergency Telephone No. __.-. _A <br /> Contracts Licence No.- _ _ <br /> Applioanls Name(Print r?+ ___- Title ata� <br /> Please cheek AppYcabte Cata9erlt(1.7)and FMt in the Rel]Yaed Inform411011 <br /> 1. G PUMPER VEHICLE►EAMf7 RE0ISTRATION(FOR EACH VEHICLE) <br /> For JULY 1.---.,..June 30.19 Disposal Site _ { <br /> Serial No. _CAL.License No. _..._-..�- __._CAL.License Renewal No. <br /> Capacdy Gel.. Weights A Measures <br /> E ul mwlt Perkin Address __.____.____._ <br /> q P g rkti <br /> 4 G PUMPER YARD <br /> Por July June 30, 16 <br /> No.Of Vehicles Iwr:A <br /> No.of Chemical Tenets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R S.or R.C.E. Name _ R.S.or R.C.F-No, _,w _ <br /> Test etfon - e. Tat Datertlme <br /> a. FASANITATION PIEBMMIT .. �( /Qr (��� <br /> I. Job Add Locat on 2 77/ E EAAr f_ fjtt; <br /> -rofct MTA Ir Co. XP'C- Address <br /> SEPTIC TANK O CESSPOOL �GLEACHING FIELD G SEEPAGE PIT 13 PACKAGE PLANT <br /> PERMANENT 13 /TEMPORARY Jar NEW ❑ REPAIR- W OTHER PZ)O V BED <br /> s. G CHEMICAL TOILETS Fs Juy 1,-June 30, 19--- <br /> Type <br /> 9_—_Type Construction _.Oleposil Site <br /> No.of Units ___.,— Equipment Slorage/Cleaning Location(s) _._ t '• <br /> 6. G PACKA08 TREATMENT PLANT For Jury 1,-June 30.19,_._ _.L <br /> Cpmtor Name, Whom CertlAed .___.—_ <br />+ PlarKLocation <br /> ( <br /> Plant Caoac,P/ _ --------- No.Units ServM <br /> 7. G LAUNUAY For July 1, •June3rh 19�.-_. <br /> SIZE: G Leas Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq.Ft. •u <br /> G DRY CLEANING.Cllemicab UsadMmountlMO. <br /> I nereby certify that 1 have prepared 'hie application and that the WorK Will be done In accordance With San Joaquin County 1 L <br /> ordinances,slate laws.@no ru1M end r vlatl 1 Me°16n Joaquin LOUT Health District \ T• /XrJP_ <br /> RPuLICAfJT'S SIGNRTUREX - .f <br /> t; FOR DE PARTMESIT USE ONLY <br /> Fee le Dur. O ANNUALLv p mot I"r O msrtt I]TACH ALnwrr+a See~er JrwMY at O Jane'►Aeewriq tin cry�L. <br /> —_ ___ �Exr;ANATI I MUM REMITTANCE ! AMOUNT OUE cNeo n � <br /> wTe wte ASMITTEo AMgINT <br /> LMp1AtION -�T� <br /> flus F. A <br /> 1 41 <br /> ones TSS/�/moi��J�. <br />:+, r <br /> _ as�BL a • <br /> efSY`�'-f41id <br /> L--_ AIKKAMT�MTMN ALL GOIaa TQ aMYraONM[M1Al NIALTN M11MRA[aWGYe rMt e.IM[aLTOM AYe.G0.aw sere a OIL EA <br />