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<br /> Applizalions Will Be Processed When Suhnu!led Properly COmPlOtPd Ile Sure To Slqn The Application
<br /> APPLICATION
<br /> L (For Non-Transfirable.Revocable.and SttspendahIe)
<br /> FI-4VIRONMEN'rAll. HEALTH PERMIT
<br /> LIQUID WASTE
<br /> L PoIebl-ad,`to C411,1 I' 1r lurs'.':One T 3" In
<br /> i3t,we'r.N." :rFIA, DA P/APFR;_ZH Li S'✓
<br /> u Frrrt Parin,,rs Arjlressrts lod T,lpp^rn,,Numhe
<br /> A.A. 3u,.,,Pss Telephone No 4!::' EME gency rctlep,tore P40
<br /> L1-ont,acto,L,cerTce N,, -2-M5--4
<br /> Ap,tu:,m,Name Irl, )-.;;,-rAt-IL.E:`/ -.- 71AV1 i Tont, I-S-)
<br /> Please check Applicable Category(1-7)and Fill in the Required Information
<br /> L 11 PUMPER VEHICLE PERMIT REGISTRATION(FOA EACH VEHICLE)
<br /> LF,-July 1, June 30. 19 L`Isp!'sal Saes
<br /> DesCr,Ptu,,r,(Make/YL.Color)
<br /> Ger.11 No. CAL License No CAL L,Cel.-e PenmARI 40
<br /> Capacit, G61 Weights&Measures rl-,
<br /> Equscm(nt Park mv.Address
<br /> im 2. 0 PUMPER YARD
<br /> or July June 30. lq
<br /> No of Vehicles Stored
<br /> No of Chemical Toih15 Shored
<br /> L 3. 0 PERCOLATION TEST
<br /> R S or R E.Name R.S. GrHCE No
<br /> Test Local-on Tcst DawT,rne
<br /> 4. GI-' SANITATION PERMIT
<br /> L JObAddYess!LOCa!,O, 109G7C) i—ti-,
<br /> Owner C#4,%r_LE_S 'ZRE:E_F�� Address
<br /> 0 SEPTIC-TANK 0 CE5SPOZX [+-rEACHING FIELD �lEPAGE PIT 0 PACKAGE PLANT
<br /> PERMANENT 0 TEMPOPARY 0 NEW L4—PIEPAIA 2'0THEP _L",ZT`M`k
<br /> 6. 5. Ll CHEMICAL TOILETS F0,J,IYl.-JLutc30. l9
<br /> Type ronshoci,on D.Sposal S.te
<br /> No of I-:,ds Eq.,p,RnI Storage,Gleaning Llic.fic,,,si
<br /> S. 0 PACKAGE TREATMENT PLANT Fur July I -June 30. 1C
<br /> Operator Name Whera Certif,ecl
<br /> Plan]Locabon
<br /> No Unit,Ss,.ed IN
<br /> Plant Capacay
<br /> 7. 0 LAUNDRY 10,July 1. -June 30 19
<br /> L SIZE 0 Less _P-11 I COU So F1 0 More TI a, 1.000 Sq F?
<br /> 0 DRY CLEANING Chemicals Used/Amount'loo
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<br /> ilial , - 1 11
<br /> .'CloatIcEs t atTr
<br /> laws.
<br /> s C1 lAts and Ht ,u,n
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<br /> "APPLICANTS XI-15
<br /> SIGNATURE 6_k,f
<br /> tron DEPARTMENT USE ONLY
<br /> 0 "'j, C ......
<br /> Fee Is Due:0 IJN,r
<br /> VASE ItIPLAI1AlION4
<br /> It I
<br /> AFL
<br /> FNuRarloN
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<br /> ECIIIII-TIETLIAN ALL CC'its I C' ENVIRONMENTAL HEALY"11RAIT sCAV I]TS so, ."E,10.AIE_10.011.0 S OCKICEICIE 515].1
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