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Appncauons will Oe rrucesseu wnen >uommeu rropeny L.ompletea. tie cure to algn the Application. <br /> APPLICATION <br /> Non-Transferable, Revocable, and Suspendablrvo <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Applicati /h�err,g�jby made to carry Qp9g b�u��In@ss in theaurisdictional area of the San aquin LD al Health Distri t <br /> m Business Name(DBA) r' KGI P5 IJ'�ClG�U'Q ��'.�. Address U IF L,'f TO.-. r V4 <br /> i Owner TN*li C'Aa6t 1� Address <br /> Firm Partners, Addresses and Telephone Numbers (� ) <br /> Business Telephone No. gz 3 r`-' 7 Emergency Telephone No. r <br /> Contractor Licence No. ,�L439! 8 c <br /> L Applicants Name (Print) !/f'1 R C"ly2tyllr. _ Title Date <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. Licz,3e 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. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S.or R.C.E.No. <br /> Test Location Test Date/Time <br /> 4. ❑ SANITATION PERMUT _ �. <br /> Job Address/Location /��=T �`-P'rar 1.08o " ' " y 1'�-o -- <br /> Owner R.E. GAren-L Address /0 SOC) & /'/w1M J!,2O A9A:711'�-9 <br /> ❑ SEPTIC TANK ❑ CESSPOOL Et LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ® REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ,L <br /> Type Construction Disposal Site A00 !G' X' /u` P$471r_ _ <br /> No. of Units _ Equipment Storage/Cleaning Location(s) N <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 O <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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,state laws,and rules and regulations of the <br /> San Joaqyp Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT 15t PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE 5 REMIT <br /> BASE EXPLANATIONAMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE !� <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Yl� -7 fia 1113o 37 q s 6 (pY571 /o <br /> Received by Date Receipt No. Permit No. lasu lice Date Mailed 4STOCON, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Soa 2009 CA 101 <br />