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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION W4(For Non-Transferable,Revocable,and Suspendable) �` <br /> eA <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> ,, Business Name (DBA) Quality Contra] Tn.spec_t_ion—I-n.c_-Address 1295 N Emerald Modesto 95351 <br /> iOwner T�]OmaS RamnoldAddress 8581 S. Van Allen Rd. Stockton 95206 <br /> j Firm Partners, Addresses and Telephone Numbers <br /> (209) 754-3588 <br /> aBusiness Telephone No. (209) 754-3588 Emergency Telephone No. <br /> Contractor Licence No. N/A Engineering-Testing-Inspection Firm <br /> a Applicants Name (Print)QCI By Jess Wry Title P.E. Employee Date 5/6/91 <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. CAL.License Renewal No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30. 19 <br /> No ehicl Stored - <br /> o of Chemic Toilets Stored <br /> 3. Q PERC LATION TEST <br /> S. or E. Name duality Control Inspection R.S. or R.C.E. No. M.S. 91- 17 <br /> Test Location See Map Test Date/Time __ 5 8/ <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30. 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq..Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> Hoare er ownorgeensed agents signature ce►ttfiesthe fo"vving:"I certify that in the performance of the work for which this permit is issued,I shall not employ any person <br /> in such manner as to become subject to workman's campensatian laws c'Catiforrua. <br /> Contractor's hiring or sub-contracting signature certifies a* following: "I cWIiy'hat in the performance of the work for which this permit is issued,1 shall <br /> employ persons subject to wurkmali s compensation laws of California. <br /> I hereby certify that I have pr red this applica ion and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, ules and regul ion of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE <br /> Jess Wry, P.E. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �r D �+ CAMOUNT <br /> Q <br /> FEE �x`W= 1 7"L � 9 2(2. oo <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receiv by Date Receipt No. Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 95201 <br />