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Applications Will Be Proces-rr When Subs:iaed Properly Completed.Be Suia To S!gn The Application. <br /> APPLICATION <br /> (For Non-Transferable.Revocabie,and Suspend.-ble) <br /> ENVIRONMENTAL HEALTH PERMITSEFTAGE <br /> LIQUID WASTE <br /> Appl cal;0 is hereby. de to carry busineEs in the jurisdictional area of the Sa aqui ocat a Ih Di nct <br /> „Business iya�e(DBA).�-`J.-Xe*A � �" Address <br /> owner_ �C _,�f SLE �__ _ Address -7 //--/"JD_�i <br /> -=.rm Partners,Addresses and Telephone Numbers__ �ce���fFl£- -�V J- � <br /> a <br /> y business Telephone No. z. j_3u Emergency Tetephone No._*5-4!L — <br /> r' Ctmtraclor Licence No. - <br /> L AplAcarts Name(Pririt) —Title _d LJ�� _Dale <br /> Please cheek Applicable Category(1-7)and Fill in the Required Information <br /> I. PUMPGR VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ! <br /> For Jt•ly 1, June 30,19 Disposal Sites <br /> - Description(Make/Yr..Color)-- <br /> --.---CAL. <br /> ___. __CAL.License No. �_ CAL.Lfcrnse P,er.cwal No <br /> CapacilIF _' _ -_-- Gat.,Weights S Measures No. <br /> i Equipment,Parking Address - <br /> 2.-,ir# PUMPER YARD etc <br /> ` FovJuly 1, June 30, 19 <br /> No.of Vehic'es Stored <br /> No.of Chemi--at Toilets Stored:_-.. <br /> 3. Q PERCOLATION TEST. <br /> . <br /> R.S.or R.C.E,tit+me R.S.or R.C.E.No <br /> A.S. <br /> z 'Te <br /> st L Cation <br /> t 4 ISANlTATiON PERMIT. p r ' r <br /> r i JOti AddreS ocatbn __�//55� C . __ _,��C•� <br /> ✓ . # Owner Ad <br /> f i RISEPTiC TANK ❑ CESSPOOLLEACHING FIELD 0 EEPAGE PIT ❑ PACKAGE PLANT "•t; ��r y; ,: <br /> ©PERMANENT ❑ TEMPORARY C1 11 REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30.13 <br /> Type Construction Disposai Site <br /> No.of Units ��'__ Equipme t Storage/Cleaning Location(s) <br /> 6. C3PACKAGE TREATMENT PLANT For,iuiy 1,-June 30.19 <br /> - Operator Name ------- - -.---------- --- Where Certifiers <br /> Plant Location <br /> Plant Capacity __-- --..-- No.Units Served <br /> T.. 0 LAUNDRY. For July 1, June 30. 15 <br /> SIZE: ❑ Less Than. 1,000 Sq Ft.. ❑ more Than 1,000 Sq.Ft. � <br /> 11 DRY CLEANING,Cnemicals Dred/AmounLMo. <br /> hereby certify that I have prepared this ap at'ion and that the work wiil be done In accordance with San Joaquin County <br /> ordinances,state l:,,a n �ret>•s d requia Yxt t San Joaquin Locai Health District .. <br /> APPLICANT'S SIG1�ATUREX - --- ---- -- ` <br /> FOR DEPARTMENT USE ONLY <br /> Fee 13 DMe:❑ A1rN'JA _ CJ PER UNIT rJ PER S.TE - ❑EACH ❑ Jaeuary S a R&Ceive eY January 31 ❑Jury 1'8 Peclrved RY Joh 31 <br /> BILLING1 REMITTANCE I S j <br /> l <br /> BASE ` EXPLANATION AMOUNT DUE KED <br /> i DATE � - DATE f -� RfMITTfU NT <br /> fFC <br /> LESS <br /> j PRORATION <br /> '-YENS i <br /> PENALTY !, <br /> OTHER <br /> OTHER <br /> L <br /> sPerml fro 13SIraMa Date � rlatNM DelnerrlA <br /> APPLICANT-RETURN A!t.CO:rES TO ENVIRONMENTAL HEALTH PERMITiSERVICES INN E.HAZELTGN AYr_P.O.aaa 100► ST ON CA 11S1at <br /> r-� - <br />