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Applications Will B icessed When Submitted Properly Completed. ;ure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in t e jurisdictional area of t e S Jo uin ocal He It Dis nct <br /> r, Application <br /> Name (DBA uaHL_ Contro� Ins ectior..,_inC Address 12�� 1 Q E4merala Modesto 95351 <br /> Owner Ji.$_#__ T_F_ ,__Gx-T_-Gulmon Address 26202 -E. Magnolia <br /> S Firm Partners, Addresses and Telephone Numbers (209) 838- / 130___ _ _ _ <br /> Business Telephone No. (209 5272�F0 _ Emergency Telephone No._(209) 527-4940 <br /> Contractor Licence No.Nlk-Engineer ing-Des t jng-IIeSpect ion Fj�� ----------- <br /> Applicants Name (Print) -C- 1 _ JQ S 8--WL -, P.E. <br /> TitleP-.E. , -EMP I G 1Pe_- Date <br /> Phase 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. of Vehicles Stored <br /> No. f Chemical Toilets Stored <br /> 3. A PERCOLATION TESTR.S. or R.C.E.Name 0-US11 ty Control Insneion R.S.or R.C.E. M'( -_92-92 <br /> Test Location 262_((�32_E.-__gnolia Escaton Test Date/Time- 7 2 _. 2:30 -- -- <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner --- Address-- <br /> 0 <br /> ddress__❑ 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, Chamlcals U /AmounyMo. _ <br /> �f'E•a'cs.� 1"/os' rFa" .r/��DE �.•? 9z-- . �.����r.J�o.�✓ �'.si fi -- <br /> I hereby Certify that I hav ared t 's application and that the work will be done In accordance with San Joaquin County <br /> ordinances,state laws <br /> APPLICANT'S SIGNATU X Title Pr PC 1 dPn t Date-_6/29/92 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 6 Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE f <br /> BASE EXPLANATION DAMOUNT OUE CHECKED <br /> ATE DATE REMITTED <br /> AMOUNT <br /> FEE / ---- - - - VV --— <br /> LESS <br /> PRORATION <br /> PWS ---- -- --- - --- -- - - <br /> PENALTY <br /> OTHER <br /> OTHER --- -----� - --- -- - - - - ----- <br /> ecerved by Oate Receipt No Permit No Issuance Date Mailed Delivered <br /> L--- •oo ,r•ut -oc�.mu•„ rnmcr rn. ruwenu••cut.. ..r..:u arn..,t,.cs..,..c� .....c ,...r.:.....,.c .... .__........ �:......:.... ...e....,. <br />