Laserfiche WebLink
P h ' der i"k ,? r i r 4 n� 1L nar3 <br /> ."iGt... <br /> t �k Li- y%iX .s 4��.�� kstU.)e•.� Y a t y F <br /> -i � .-.,. `•.a:k::...�..++' r..ra�t°oi.,a Ax..t'+«S ir.s'n'c,�s. w..�rsczyo-r;.«r•+-�.rru..�'4fi'tlY:E?ysLwWi,. --.. 'i <br /> t Applications Will De Processed When Submitted rroperly Completed.Be Sure To Sign The Application. <br /> s APPLICATION <br /> (For Non-Tranafarsbla,Revocable,and Susperdable) <br /> ENVIRONMENTAL HEALTH.PERMIT f <br /> - LIQUID WASTE _ <br /> ` App'Icalionis/�reby m,ide{^carry on iness In Ne nsdictlonai area Of:he n oa,q�I_rt Locel eelt }�'ric: <br /> c" m Eusmess Name(DE?4) / _- <br /> '•r' ya Owner - - _ AdGress <br /> rr,.Panrim, Addressesand rate he a Numbers— <br /> a?usiness.?elephore No._ - _ 6Emergency Telophonn No. — — <br /> Contractor Licence NO._ <br /> A `Applicants Name(Print) r __Title _ j7, Date _a_1_�_c-..— r <br /> Please check r nolluble,Category(1-7)and Fill In the Required Information !!1 I <br /> 1. 11 PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> �`. ._..h_.._ <br /> ForJuly I,'--June 30, 19 Disposal Sites <br /> Description(Mska'Yc,Cn!o:', _ - <br /> Serial No._._______- -_CAL.License No.. -_ _CAL.Unease Renewei No <br /> Capacity—_ Gal..Weights 8 Measures No. <br /> Equipment Parsing Address <br /> 2. ❑ PUMPER YARD -For July 1, June 30, 19 - <br /> -No.of Vehicles Stored <br /> J <br /> 'No,of Chemical Toilets Stored <br /> j 0...❑ PERCOLATInN TEST <br /> R.S.or KC E, Name - _ -R.S.or R.C.E.No. <br /> T= Clition Test Date/Tirr.e —_ <br /> i 4. YSANITATION EERM111` - <br /> i Job Address/ <br /> Y`i Owner ' dd.� <br /> ] SEPTICTANK11 CESS?O� AteHING <br /> FIELD ❑ SEEPAGEPIT:- 0�-y PACKAGEPLANT <br /> ❑ PERRdAr ENT+ M <br /> ' I] TErtORARY NEW. IXREPAIR API-OTHER 00FJ$/U e6P <br /> c2 5. ❑ CHFMICAL TOIL tTS Foi Jul,,i -June 30, 19 _ <br /> t Typo Con <br /> structlon Disposal Site <br /> s� No.of Units Equipment Storage'Cleaning Location Is)__ 1V; <br /> 6 I?-PACKAGE7REATMENT I-LANT= For July 1 -Juno`80 19 <br /> Orator Name _Where Certified <br /> Plant LaCat cn. <br /> Plant Capamty_ No.Units Sen'ed _ I <br /> 7. ❑ LAUNDRY For JUiy1, June30, 19 <br /> ^` SIZE: ❑ Less Than 1,000 Sq.Ft,, ❑ More Than 1,000 Sq. Ft. <br /> k: C3 CRY CLEANING,Chemicals Used/AT90OnbMO. <br /> ( ger b,•� y that i-neve prepared ;his application and that the work will be done in accordance with San Joaquin^ County, <br /> - ordinances s`a'e aWS,and rules d regulation of the S o quip L-Health Dlstr Ct. <br /> APPLICANrSSIGl0TUflEX <br /> — ^i - FOR DEPARTMENT USE ONLY --��--- "• "k, <br /> Fee is oue: ❑ ANNUALLY ❑ PER UNIT ❑ PEO SITE ❑ EACH ❑ January 1 A Rere ve By Js,'3� ❑ Ju y 1 8 R"A,,bl 8y J ry T <br /> I,y <br /> R <br /> -BASE EXPLANATION BILLING REMITTANCE AMOUNT DUE CEMKEO <br /> )$-. .. —,_-_-.- —_ <br /> OAT DATE REMi^EDE — __ AMOUNT <br /> 14T,y ti vx'. <br /> _— <br /> LEIS <br /> PRORATION _P <br /> 1 v 'pPNALTV <br /> b OTHER <br /> OTHER— <br /> Rxe,.me W Osie FrKe.;,i o. Pe. I No Twwn Za•e-- :nerve <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMR/aERVICEa 1101[.HARLTON AYC_R Kp -STOCKTCN,CA 05E01 <br /> f <br /> -y V i � � A � � ���T'T•G•'i ` YS Y i6YJbTMrM�3L5+<E Ji-^1MC } <br /> R fa 4 4y� <br />