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Applications Will Be Processed When Submlttetl Prop ly Cornple ed.Be 'fo�5ign The AppllCatiOn. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and SuspendaDle) <br /> ENVIRONMENTAL HEALTH PERMIT -�� ,4 �dpARCEts <br /> -' LIQUID WASTE f <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) Address <br /> Owner F T RFD MASOtJ, Address n 1 <br /> 3 Firm Partners,Addresses and Telephone Numbers - C -Ty�A�L�e\�2t.11 A 9=�4,-A2 <br /> $� Business Telephone No. Emergency Telephone No. 745-7-8L;"(,� a <br /> j Contractor Licence No. <br /> L Applicants Name (Print) \VALTE1-;=SL 1Ftnri Title IV IL N +IMi=F Date II-14+-92 <br /> Please check Applicable Category(t-7)and Fill In the Required Inlormatlon QC E.ik11584- I <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) 4-elAA-'NENt PLAZA, toCA•'9524'0 <br /> For.July 1, June 30, 19 Disposal Sites ��6g�3(.oQi"4-IS9 <br /> Description(Make/Yr.,Color) <br /> Serial No. CAL. License No. CAL. License Renewal No. ~ <br /> Capacity Gel.,Weights&Measures No. <br /> Equipment Parking Address r <br /> 2. ❑ PUMPER YARD MS-91"40 f <br /> For July 1, June 30. 19 <br /> No.of Vehicles Stored 2 i-AscGE1.S <br /> No.of Chemical Toilets Stored -g-41s9 <br /> 3. 0 PERCOLATION TEST MJC1Z'H'CVVI PLA�AJLQp1yCY\. 982.40 h � rZ"3�3"�Ti>'F�'IT>=1�9�} <br /> e*=R.C.E.Name R.S. or R.C.E.No. PARGEi 1 .2.3o-3:OOPN1 (F-1-1-92�r <br /> Test location 2G,34 9 9 RQVZnA Nlc Test Date/Time i <br /> 4. ❑ SANITATION PERMIT GALT;C A. SGBZ: 3IEE PAIIL y <br /> Jae Address/Location %IM-M S�fLET ; <br /> Owner" Address \ <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PL: NT le <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER1 Yui�� <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 ,(i { T' X_ <br /> Type Construction Disposal Site A <br /> No. of Units Equipment Storage/Cleaning Locations) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30. /9 - cr <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served O' <br /> 7. ❑ LAUNDRY For July 1,-Jure 30, 19 tip <br /> SIZE: ❑ Less Than 1,D00 Sq.Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/AmounVMO. _ <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 /> .yyam� ciVIL E'NCitNEEp t(-I�- 2 <br /> APPLICANT'S SIGNATURE X THIEF,;-_e•Ile.lied- Date <br /> FOR DEPARTMENT USE ONLY - <br /> FN Is Dila:❑ ANNUALLY [3 MR UNIT ❑ PER SITE ❑ EACH ❑ ismary 1 a RwAived By Jaru 31 0M 1 a Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BRLiNG REMITTANCE = AMOUNT DUE CHECKED jn1 <br /> GATE O TE REMITTED AMO V <br /> FEE — — <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER K <br /> Y <br /> OTHER <br /> elved by Dae Receipt No. Permit Nolasuance ale Mailed Delivered <br /> • iCANT RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 11101 E.HAIELTON AM.P.O.Box 211100 STOCKTON.CA 95201— <br /> ' <br />