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Applications Will R•Protested When Submltlad Properly Completed. Be Sure To Sign Th' plication. <br /> APPLICATION <br /> (For Non-Transferable,Revo'able,and Suspendable) <br /> ENVIRONMENTAL HEAL rH PERMIT <br /> LIQUID WASTE <br /> Application is by ri Ade 1nOJ /'busines the iurrsQrctlona!Arne o!the S )oaquln LocAI Hoaltn Drstr <br /> Business NRme A GC's-A C/ ✓ <br /> 1 G 1 jC2y► 1� ��I���,+ Address �G �..��^�� � •Tt � <br /> Owner �.r �/ r Adress <br /> Form PRrtnr-rs, Addresses and Telephone Numbers <br /> E usmess Telephone No 3e,-,9•r i C <br /> Emergency Telephone No <br /> Contractor Licence Not / �1 L _► <br /> Applltants Name(Pnnl) ili1l L- f .4'a Title !f'��-' Date Ar 7 A <br /> Please cheek Applicable Category(1.7)and Fill In the Required Information (�J! <br /> 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR E4CH VEHICLE) <br /> Fcr July 1, June 30. 19 Disposal Sites <br /> Descnptlon(Make/Yr..Color) <br /> Sorol No CAL License No. CAL.License Renewal No <br /> Capacity GRI Weights A Measures No <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> Fol July 1. June 30 19 �. <br /> No of Vehicles Stored <br /> No of Chemical Toilet- Stored +O <br /> 3. ❑ PERCOLATION TEST <br /> 4 <br /> orRCE a RS.orRCE.No. --}}--- r <br /> Test Date,Time__ �J.. ✓" <br /> 4. ❑ SANITATION PERMIT ,(,.,� ��I <br /> Job AddressLocation✓xL 414 "(At Rplpe <br /> C�Jwr AddreSa <br /> laT ,OPTIC TANK 13 C'SSl'OOL t— r lfcACHINO FIELD C�¢EEPAGE PIT ❑ PACKAGE PLANT <br />❑ I EP.MANENI ❑ rEN''ORARY [?'NEW C REPAIR O OTHER <br /> 5. ❑ CHFM,.;AL TOILET' For;my 1, -June 10, 19 <br /> Tyc*Construction--- ----- — _ -- Dirposal Site--------_---- <br /> No of Unit; - _ - _ _ Equipment Storage/Cleaning Locauon(s) -- <br /> 3. C PACKAGE TREATMENT PLANT Fc•Ju!y 1,-June 30, 19 <br /> Operator Name Where Certified _ <br /> Plant Loca•hon <br /> Plant Capac1ly No.Units Served <br /> 7. ❑ LAUNDRY For July 1.-Jur.o 30. 19 <br /> SIZE ❑ Less Than 1,000 Sq Ft. ❑ More Than 1,0D0 Sq.Ft. <br />❑ DRY CLEANING.Chemicals UsediAmount/MO. <br /> O <br /> w <br /> 1 hereby Certify that 1 have prepared this applica•ion and that the work will be done in accordance with San Joaquin County <br /> ordinances,stale laws,and rul And regulations Sao Joaquin Local Health Dhtrict vr, <br /> APPLICANT'S SIGNATURE X .�d!' <br /> FOR DEPARTMENT USE ONLY <br /> Fee It DUs' ❑ ANNUALLY ❑PER UNIT ❑PFR SITE ❑ EACH ❑ January+A R anus J J ty 1Jn,!!-Ry-julyJI <br /> _-_-_ _ -.- _ - ____ ___ _ _ __ <br /> j R0.LING REMITTANCE /\+ 5 REMIT <br /> MSE FIIPLANATIOr. A O T CHECKED <br /> uATF DATE //HEMITTE <br /> _ v _ _ AMOUNT <br /> LESS J <br /> PApAA11ONPL us <br /> PE Peat^_ <br /> - <br /> t <br />