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Applications Will Be Processed When Submitted Property Completed.Be Sure To Sign The APPIkEtbn. <br /> APPLICATION <br /> _ (For Non-TrmNasble,RevoeMM,sued Suspaall SEPTAGr <br /> - ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> AOplioatWk h msA3e On ml s In the jurisdictional area of t n JOEgylg LOUI IN Die <br /> 3usiness Name(OBA) � ��.-4 t,�c. Address. <br /> Jwner _ Address <br /> Firm Partners.ADOreases aMpThon*NumbersBusiness Telephone No. �7 Emergency Telephone No. <br /> ;ontractor Licence No. 2 1 <br /> 111- <br /> Applicants Name(Print) .bre __Title 1 <br /> Please check AppacabN category(1-T)and FIB In the Required Intonsabat ,J <br /> 1, ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, June 30,18 Disposal Sites <br /> Description(Make/Yr.,Cc" . <br /> Serial No. _ CAL.Lifers No. _ CAL Lberwe RarlewsY Fb. <br /> Capacity Gal.,Weights 8 Measures NO. <br /> Equipment Perking Address <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 __ I <br /> No.of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST -- r" n <br /> R.S. or R.C.E.Name _R.SorFLCA N%;-1 ;j ' <br /> Test Location _— r_ <br /> TNI 0111VOTI1M Y -,:;�2.., <br /> e.X SANITATION PERMITr --u- <br /> Job Address/Locatlon— T <br /> Owner _ y-filae0 13J i,)M _ Address <br /> 9SEPTIC TANK O CESSPOOIi JWLEACHING FIELO -MSEEPAOE'k`!`-`t PAtCKAGE PLANT M l <br /> -0 PERMANENT 13 TEMPORARY ELNEW O REPAIR OTHER f <br /> 5. 0 CHEMICAL TOILETS For July T.-Ju-ne'3U, 10__ ... I <br /> Tvpe Constructlon OisposN&b No.of Unita EquipnNnt,4twopyClMMnq LofatlonlR <br /> S. ❑ PACKAGE TREATMENT PLANT For duly 1.j JUM ig.1�__-�► I <br /> Operator Name ----- _ Wheat CRtllled <br /> f <br /> Plant Locution - --.---- ---Yr-i i;1 <br /> Plant Capacity <br /> vr `a•+� ' <br /> T. ❑ LAUNDRY For July/,-June 30. 19 S <br /> SIZE: ❑ Less Than 1,090 Sq,Ft., 0 More Than 1,000 Sq.Ft. <br /> O DRY CLEANING,Chemicals used/Amoum/Mo. ---T <br /> I hereby certify that I held prepared this appllutlyl and that the i rk will be done In axordance With Sin Joegldn GO" <br /> ordinaries,stats laws,and rules twnlIlion Joa3ulf oeN Noah District. , <br /> APPLICANTS SIGNATURE X <br /> POR DVMTMENT USE ONLY <br /> Fee M Deals O AIaA1KLY F I 1a to O Q Aiar r 4l eeww w+ $1_ <br /> a1LLINO r"IT1�I AegIMT WF i <br /> DATE OATS law,mo__ k <br /> FEE <br /> LESS <br /> PLUS <br /> OTHER <br /> OIHER <br /> Ce�Mwe W 1...:4 ..-AN I ; <br /> AERICAMT-aanwll Au uroews to awealONlIFAI MYTH selrle/eOlewaa reet L llNal mommomm mum <br />