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"Applications Will Be Proces4ed When Submitted Properly Campteied.Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Nan-Transterab)e;RevoGsbte,and SuspenAObft) SEFTAGP <br /> ENVIRONMENTAL HEALTH PERMIT <br /> t UQUID WASTE <br /> Application is hereby m de to carry on business In the jurisdictional area af•ihe San Joaqui pCelalih Di riot <br /> wBusiness Warne(ODA) 1-- L__L Address - <br /> rcOwner' [Vt`e^--- I Address— -- <br /> 3,Firm Partners,Addresses and Telephone Numbers <br /> Business Telephone No. 4 Emergency Telephone-No. L <br /> Contractor Licence No._ , ) <br /> L Applicants Name(Print) Title Date <br /> Please check Applicable Category(1-7)and Fill in the Required Informatlon <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) ` <br /> For July 1, June$0,19 Disposal Sites <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL License Na. CAL.Liccise Renewal No. <br /> Capacity Gel..Weights&measures No. <br /> ,Equipment Parking Adgress. _ .". �« ..•.�. ,« .. __.... ._ •.-- <br /> 2. ❑ P.UMPER YARD <br /> For.July14 June 30, 19 - ^"-• a <br /> No`oI Vehicles Sloled - } t <br /> K <br /> NO."of Chemical Toilets Stored__ <br /> S. 0 PERCOLATION TEST .' - '•:" „. "; <br /> .R.S*or R.C.E Name A. AS.or R.C.E.No. <br /> %Test Location Test Date/Time- <br /> 4. J SANITATION`PERAIT <br /> Joti.Address/t_ocatton���D ~��.��`# � ; ,--• - - <br /> Owner ag Cv;"^ ` '"r0` Address <br /> ❑ SEPTIC T NK ❑ CESSPOOL"— ' LEACHING FIELDEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENTS© 'TEMPORARY NEW + rSt REPAIR ❑ OTHER � <br /> S.-0 CHEMICAL TOILETS 'FdrJuly 1.=June 30, 19 Y <br /> Type Construction Disposal Site ; - - } f <br /> No,oi UnitsEquipment Storage/Cleaning Location(s) " 1 • . <br /> 8. Z3 PACKAGE TREATMENT PLAINT IFor-July 1,-June 30,19 <br /> Operator Name W ererer3ifled <br /> Plant Location I 4 <br /> Plant Capacity ' No.!.Inns Served <br /> 7. 13 LAUNDRY For July 1,-line 30. 19 <br /> SIA: . ❑ Less Than 1,000 Sq,ft.. 16 More Than I Arm Sq.'Ft. <br /> D DRi''CLEANING,Chemicals Used/Amour) Mo. <br /> I dei yam► <br /> _ r <br /> fi ttereby certify that i hBYe.prepared this application and that the work will•be done In accordance with San Joaquin County <br /> ordinances,state laNr.jktd rules and regulations of the San Joaquin Local Health District. 1 <br /> APPLICANT'S SIGNATURE X— �� Y <br /> { <br /> Q, <br /> FOR DEPARTMENT USE ONLY <br /> 4 Fee-Ig--Due-❑ ANNUALLY-a- i3 PEn-uNr r ❑PER SITE ❑EACH ❑ January 1.a Received By January 31 ❑Jury 1 8 Raceived SY July 3t <br /> 10 y t4 I;+► XPL . BILLING- fiumTTANCE S REMIT <br /> J ( BASE E7CP1_ANATIQN AMotJNT DUE AMOUNT <br /> Y, '•,/ �. � DATE DATE flER11TrED - � AMOUNT <br /> FEE <br /> , '� �� x <br /> 7 � h7fc.o7� _ <br /> PRORATION + I 1 i"'0 <br /> PLUS <br /> PENALTY 1.. ,.• d4 i <br /> •� � '— � <br /> i OTHER- T .��T✓ I 1 <br /> t <br /> by Gets I Reoeipl NO Permit No. I=Mnce mrs mallm DWiVered <br /> • .. 'APPLICANT--RET $W ALL COPIES Ta: tNY1a WMWTAL HEALTH PE111A1TISERYICES im E-m*zE.TON AYE..F.O.bps am -McKTON,cA"M r k <br /> All - 1 <br />