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y - Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) Ms_92 _6-7 <br /> ENVIRONMENTAL HEALTH PER IT <br /> LIQUID WASTE ,�,oy os3aw <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health Dust; 7J <br /> „Business Name (DBA) Address _ <br /> Owner TAC-KM POLK Address 10>~4R N -fAcic_F&sIF RQA>�rlcKtz+��a. 95212 <br /> u Firm Partners.Addresses and Telephone Numbers 209) 931—mg i <br /> Business Telephone No. Emergency Telephone No. <br /> d Contrector-ALiceoce No. _ <br /> LAPplicants Name (Print) WALTEf2 F. CL)(2�-M Title CN1L RyCTI LIF F62 Date <br /> Please check Applicable Category(1-7)and Fill In the Required Inlormagon 416 M1fTTNE1N FRAZA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) Latsi ICALtF;;0RNjA 9524.o <br /> For July 1, June 30, 19 Disposal Sites C2o913G,8^41x9 <br /> Description(Make/Yr..Color) <br /> Serial No. CAL.License No. ,,,, CAL.License Renewal No. <br /> Capacity Gal.,Weights 6 Measures No. _ <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No.of Vehicles Stored <br /> No...�o(f Chemical Toilets Stored 4-ts MA-t•Tt4sw PLA A�bA i C`A 9SZ4-0 <br /> 3. Pt PERCOLATION TEST (Zo9) 3(2,6-4ts9 ® MS-92-67 <br /> R.S.or R.C.E. Name L CU S o/ $mac R.C.E.No. 11SR 4-- <br /> Test Location (SEV RSVER%UZ stvg 4oti PARCEL MA7•v Teat Date/Time EIMS`av C"rS"92= RAtipL4G­N S-L-7924. ❑ SANITATION PERMIT _ W,II CA I.I' o �9(l�'tfrn <br /> Job Address/LocationI �9 1 -TA 1 I2 hD' •� �Ta^_Jt� !`A 5212 <br /> caner <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT" ❑ PACKAGE PLANT / <br /> ❑ PERMANENT ❑,TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER v, <br /> S. ❑ CHEMICAL TOILETS For July 1,-June X 19 <br /> Type Construction � Disposal Site <br /> a 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 If <br /> Plant Capacity No.Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 (7 <br /> SIZE: ❑ Less Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq..Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/MO. - / ` <br /> PQM Shll f!3- rz•P.. n1 <br /> I hereby certify that I have prepared this application and that the work WILL be done in accordance with San Joaquin County, <br /> ordinances,state laws. t �/� ,�..��..---- <br /> APPLICANT'S SIGNATURE X k�b�AA/ ir, Title G!VIL EIN +l t.1—' 'R Data '4--3o-92 <br /> ( <br /> ` FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 a Received By January 31 ❑July 1 A Receded By JPIY al <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED ' <br /> /�]1 t ^^ [• - DATE (,,� DATE q REMITTED AMOUNT_ <br /> FEE ID(.- P� /1�00 YLN 13�� I�V IL- LOO .Q(� <br /> PRORATION <br /> vuUS <br /> PENALTY — <br /> OTHER <br /> OTHER q <br /> O /2� <br /> Recelred Ify - Otle - Receipt NO. Perms No. Issuance Oete Mailed Delivered - <br /> AINNUCANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 F HAZELTON AVE,P.O.Bot 2009 STOCKTON,CA a620t <br />