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Applications Will Be Pr, sed When Submitted Properly Completed. Be To Sign The Application. <br /> APPLICATION 4,13 2D 34v3 -al <br /> (For Non-Transterable, Revocable, and Suspendable) - Z I �-7 <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carryon usiness in the jy risdictional area of the San Joaquin Local Health Distrir,��t <br /> Business Name (DBA) Z5 •�� t 'Qil'Qr`-���`�7araS Address 2'133"1 5. ��r-A LrJ <br /> Owner__�i'Zet2-[z rraP�MA� Address S. Z^^1 T"a IZn• i ei'1 G 53"1 to <br /> ' Firm Partners, Addresses and Telephone Numbers KLS1NFE1.-r>c L. INC, • 2.t,27 e. Mu eAnm1=_ <br /> Business Telephone No. g4f5 - 15,457 Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) I.409A=994 Title E^Ib• Date It [/f3/q2 <br /> Please 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. of Chemical Toilets Stored <br /> 3. 4,PERCOLATION TEST <br /> R.S.or R.C.E. Name 17 .," I{L-1 rJ Zz:" R.S. or R.C.E. No. 2C Z=✓rJ <br /> Test Location — `•� M�f' V"t-jE rZO• Test Date/TimPr TD ITS cLM'T�J L- "'f p^"T��'-14^a• <br /> 4. ❑ SANITATION PERMIT /I•D - C 4 - j EFZ_T ' <br /> .lob Address/Location <br /> Owner — Address - <br /> ❑ SEPTIC TANK 0 CESSPOOL ❑ LEACHING FIELD 0 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: 0 Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. FL <br /> ❑ DRY CLEANING.Chemicals Used/Amount/Mo. <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. <br /> APPLICANTS SIGNATURE X `"+ , l Title hTR¢ EINV� Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: 0 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I a Received By January 31 ❑July 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE f AMOUNTOUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> D� <br /> FEE �/ <br /> LESS _ <br /> PRORATION <br /> PLUS .kS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received py Date Receipt o Parmd Na Issuance Dale Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES 0: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1 W 1 E.HAZELTON AVE.,P.O.S3.2XI3 STOCKTON.CA 3520 <br />