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Applications Will Be Prr %sed When Submitted Properly Completed. Be S, To Sign The Application. <br /> rr APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> 3usiness Name (DBA) -QUality Control Inspection , InCAddress 1295 N. Emerald Modesto 95351___ <br /> Dwner MMS__&—Ars . Bill DeG_r_o_o_t Address 22713 E . River Road <br /> =irm Partners, Addresses and Telephone Numbers X209) 838-2-9-6-1--- <br /> Business <br /> 38-2.9-6, __Business Telephone No. (2ng) 527-4940 Emergency Telephone No. <br /> Contractor Licence No. N/A__ Fnginearring Ta.--St i ng_TnspPrt i nn Firm <br /> Applicants Name (Print) loss Wry ' P F _ - Title P_E_y_--Efnpiny_P_e— Date 1 0/1 3/92 <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. L9 PERCOLATION TEST <br /> R.S. or R.C.E. Name Quality Control I-ns_pection, IncR.s. or R.C. . MS-9 — 1 <br /> Test Location See Map-_- _ _ Test Date/Timet Will Call <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location -__ - ]I <br /> Owner - - ___ -- Address - - -- <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ 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: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, hem icals Used/Amo - <br /> ��,�� �`� ✓f? �EG��G /~/�c � <br /> 0 w'1r <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 la <br /> APPLICANT'S SIGNATURE X _ _ Title P .E . Date 1 0/1 3/9 2 <br /> FOR DEPARTMENT USE ONLY <br /> Fee I5 Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE jf EXPLANATION BILLING RE T NCE I $ AMOUNT DUE CHECKED <br /> DATE TE REMITTED AMOUNT <br /> FEE D --- <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY - <br /> OTHER — <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />