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Application i r- Business Name -"A) <br />z Owner ,g— -Address <br />2 Firm Partners, Addresses and Telephone Numbers <br />Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non-Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT <br />LIQUID WASTE <br />ctional area of the Sajioaqui Local Health Di stric <br />Address 7i;" 7 eby mad o carry on sines in th juns <br />s. Business Telephone No. <br />LI Contractor Licence No. <br />L Applicants Name.(Print) _ <br />Please checkAriblidable;aiigory (1-7) and Fill In the Required lnformaIon <br />1. 0 PUMPER -VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July July 1, June.30,-19 <br />Deist n alZe/Y <br />Serial No. 'lb._ . N:14 CAL. License No. CAL. License Renewal No. <br />Capacity <br />Equipment Parking Address <br />Gal., Weights & Measures No. <br />Disposal Sites <br />Emergency Telephone No <br />TItle <br /> OMB 1-302 <br />le4 <br />-7- <br />- <br />tzcda— <br />PACKAGE PLANT <br />OTHER <br />A.S. or R.C.E. No. <br />Test Date/Time <br />Fee IS Due: 0 ANNUALLY <br />LESS pFtORATION <br />0/HER <br />OTHER <br />PLUS <br />PENALTY <br />BASE <br />, <br />4 e- . J',Irt --) • • <br /> <br />----_____ flP i i r , ., ir-li T <br />r ti— ---e <br />VOR DEPARTMENT USE ONLY <br />0 PER UNIT cirPCR SITE 0 EAcii 0 Jonuory 1 f..1-lecelved By Jenuary ',31 ,. <br />I i <br />— REMITTED <br />Roceiol N. Permit No <br />ENWRONMENTALHEALTH .PEIR PA iTfia ER VI CES <br />issuance Date <br />1601 E HAZELTON AVE.. P.O. 603 V09 6TOC ON. CA 96 01 <br />ge,viVer 2/11/ <br />' AMOUNT DUE <br />luly I & Received By July 'it <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />Received by Dale <br />APPLICANT—RETURN ALL COPIES To <br />Ter's" <br />EXPLANATION BILLING <br />DATE <br />REMITTANCE • DATE <br />1 <br />— <br />ola.,..•••••••••. <br />SE PT AGE <br />2. 0 PUMPER YARD <br />ddresV gr <br />SyTIC TANK CESSPOOL CHINC FIELD SEEPAGE PIT 0 <br />IIM4ERMANENT 0 TEMPORARY NEW 0 REPAIR <br />For July 1, June 30, 19' <br />No. of Vehicles Stored <br />of Cheminal Toilets Stored! <br />3. 0 PEF1OLATION TEST <br />R.S. or R E. Name <br />Test cation <br />4.0 SANITATION PERMIT <br />Job Addre ation 2 040 2- <br />er P11.-16 V <br />0 <br />0 CHEMICAL TOILETS For July 1, - June 30, 19 <br />Type Construction Disposal Site <br />No. of Units Equipment Storage/Cleaning Location(s) <br />0 PACKAGE TREATMENyLANT For July 1, - June 30, 19 <br />Operator Name <br />Plant Location _ <br />Plant Capacity .....,.. _ No, Units Served <br />2-. 1-1 LAUNDRY For July 1,41.J4u‘ ne 30, 19 <br />.44Ar <br />SIZE 0 Less Than 1,000 Sq. Ft., 0 More Than 1,000 Sq. Ft., <br />0 DRY CLEANING, Chemicals:Used/Amount/Mo. <br />• <br />Where Certified • <br />fi <br />>e" <br />- I hereby certify that I have prepar ,fps application and that tbe:wOric will be done In accordance WittiSari Joaquin County <br />ordinances, state laws, and rol n egulation4 th an Joaquin Local Health District. <br />.e2erze.../_90 1r 4. <br />e <br />APPLICANT'S SIGNATURE X