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Applications Will Be Pt ssed When Submitted Properly Completed. Be To Sign The Application. <br /> �s APPLICATION %10 <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 /> ,, Business Name (DBA) Quality Control Inspection, IneAddress 1295 N. Emerald Modesto 95351 <br /> owner Steve Fredriks /� Address 22611 S. Austin Rd. Ripon 95366 <br /> ' Firm Partners, Addresses and Telephone Numbers -\20� 599-3644 _ --- <br /> Business Telephone No. Emergency Telephone No._�269' 527-4940 <br /> Contractor Licence No. N/A Engineerin -Testin -Ins ection Firm <br /> Applicants Name (Print) Ss WryTitle P.E. Em 10 ee Date 1/19/93 <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. <br /> 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. M PERCOLATION TEST <br /> R.S. or R.C.E. NameQ>Ia I_UY Co.ntrod 1nspectioi R.S. or1R.C.E. No. MS-92-164 <br /> Test Location 9720 Sda n-Ave (Se-112--Map-)- Test Date/Timed Wil ] C'.a 1 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <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. ❑ LAUND_,fr-'J`-fT' -'fane <br /> S --- _ Less Than 1,000 Sq, Ft., More Than 1,p <br /> DRY CLEANING, Chemicals Used/Au Mo. 7tllliii�� <br /> a ave prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X ES W R Title�I�j!�SIDF5IT - ,� Date 1 <br /> .E. <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received Sy January 31 ❑ July 1 &Received By Juiy 31 <br /> REMIT <br /> BELLING REMITTANCE $ <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> ctl J 1r.0 l AMOUNT <br /> FEE 1-015 1 q 3 � /P <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 3 37 <br /> ? <br /> Recaiv¢d by Date Receipt No Permit NO, <br /> Issuance Date Maiied Delivered' <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2002 STOCKTON.CA 95201 <br />