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F <br /> tApplications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> ' (For Non-Transferable,Revocable,and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT /� /v Y✓ o�J y <br /> LIQUID WASTE <br /> Application i ereby m@de to car On business in theejjuurisdictional area of 111.San,J/oaqu�Local Heal Istria[s� , l` <br /> Business Name(DBA) E D A2 E L ��•—k Address�J_L�N <br /> Owner Address <br /> t — <br /> Firm Partners, Addresses and Telephones N_umbberrs� <br /> '$ Business Telephone No. Emergency Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) 1-+� .-o-Demi —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.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 le <br /> ' 3. ❑ DILATION T T �� - IZ•y.9st9 I!fl 3o A H <br /> R.S.d C:E. ame L-O E t_ b U -.,x R.S. R.C.E. No. <br /> ??e.2, 'til?s"R.:;. _ a^ Test DatelTlme <br /> Test Location ----- _ <br /> 4. ❑ SANITATION PERMIT M•SQ,Z� 0 1-34 'Z: '(�Sis '� (JES� Of EXISTI JS <br /> ' Job Address/Location <br /> Owner Address <br /> 11 SEPTIC TANK 11 CESSPOOL ❑ LEACHING FIELD 13 SEEPAGE PIT PACKAGE PLANT v <br /> ❑ PERMANENT ❑ TEMPORARY '❑ NEW ❑ REPAIR ❑ OTHER a . \ <br /> ' S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 <br /> Type Construction Disposal Site -� <br /> No.of Units EgJipment Storage/Cleaning Location(s) <br /> S. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 -\-i <br /> Operator Name <br /> Where Certified <br /> Plant Location <br /> ' Plant Capacity No, Unita Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. n <br /> ❑ DRY CLEANING,C ,emicala UU etl �o�un o <br /> ' I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County r <br /> ordinances, state laws. /� r.A <br /> 6'�/I/_•(' .(_JgL.00/Jn.w..-�_ Titla — Date <br /> APPLCANT'S SIGNATURE X -, <br /> FOR DEPARTMENT USE ONLY <br /> Fee is Dae: Q ANNUALLY ❑ PER UNIT ❑ PER SITE 1 ❑ EACH [3ry Janua16 Received By January 31 ❑ July 1 a Rscaly REMIT ly 31 <br /> BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> BABE EXPLANATION' DATE DATE REMITTED AMOUNT_ <br /> E <br /> LESS <br /> ' PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> R eIV by Receipt No. Permit No. Issuance Date Mailed Deiivereo <br /> PLI \ <br /> �- APPLICANT-RETWIN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES �.,��-ELTON AVE.,P.0-Boa 20011 STOCKTON,CA 9520/ <br />