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Applications Will Be r sated When Submitted Properly Completed.Br<--�:a To Sign The Applivollon. <br /> APPLICATION <br /> (For Non-Treneferabte,Revoctlble,and Suspendable) <br /> ENVIRONMENTAL. HEALTH PERMIT <br /> LIQUOR WAM <br /> Application is hereby made to carry on butinesti in the jurisdictional area of the San Joaquin Local Health District <br /> rBusiness Name (DBA) -QUA1-kty CQntrQl _InMger,tion Inc Addryss 1215--X. _$Me1�1$- H <br /> Owner Riyer_Valley Ranch Address 352$ Oakdale Rte_ Modesto __95355 <br /> Firm Partners. Addresses and Telephone Numbers 551 -3 8 1 f) <br /> Business Telephone No. 527-4940 Emergency Telephone No. _ — <br /> i retractor Licence No. MIA En ineerin -Testint -Ina ection Firm <br /> pplicants Name (Print) QCI by Jess Wry, P.E, Title EMPlpyee Date-3L--19/93 <br /> Pipe"check Applicable Category(1-7)and Fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FDR EACH VEHICLE) <br /> For July 1, June 30, 19 Disposal Sites <br /> Description(Make/Yr.,Color)— -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. <br /> tored.3. IN PERCOLATION TEST <br /> R.S. or R.C.E. Name Quality Control Inspection R.S. or R.C.E. No. 143-92- 156_ <br /> Test Location See Map Iiia. rtl I,IG,.> d Test Date/Time Will 1 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKACaE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY I] 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(sl . <br /> 6. ❑ PACKAGE TREATMENT PLANT Fat July 1. -June 30, 19 — k' <br /> Operator Name _ _ Whore Certified <br /> Plant Location <br /> Plant Capacity No. Units Served - <br /> 1. ❑ LAUNDUY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1.000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amourtt/Mo. _ <br /> /iS � p- /4 rH-- 7✓S� �, <br /> A.-�tsr s n4 arf�htllttt�A-- � 3��► r' r/d� <br /> I hereby cert i ve prepared 1 ie application and that the work Will lie done in accordance with San Joaquin County <br /> ordinances, tate laws <br /> APPLICANT'S SIGNATURE X __ Title President pate 3 19/9 3 <br /> FOR DEPARTMENT USE ONLY <br /> FN la DYe ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH Q January1;RaGill"d byJutl+ary 31 O Jwy t a R6cs1r64 8y July 71 <br /> BILLING REMITTANCE REMIT <br /> BASE EXPLANATION DA7E OATEE REM TTED A DUE CHECKED <br /> ---,/ AMOUNT_ <br /> FEE NO <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> dY R+16 REcvip1 No P6rmn N0 166uancE 6116 M44led Potiwnd <br /> APPLICANT—RETuIIiii ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/4E1PIVICE4 1601 E.HAIELTON At1E.,P.Q.Box 700E STOCKTON.CA EW <br />