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� mei,iirrs.a—a=•--.wne� <br /> Applications Will Be Processed When Submitted Properly Completed.Be Sure To Sign The Application. <br /> APPLICATION <br /> ' M (For Non-Transferable.Revocable,and Suspendable) ��� 0�` <br /> ENVIRONMENTAL HEALTH PERMIT AGE <br /> LIQUID WASTE <br /> Applicat#ion is hereby ma letocarryon busin s in th ju 'sdictional area of the Sandaqui Local Health Dis nct <br /> O Business Name (DBA) 4- — Addresses l (�.f #�� <br /> Owner J�_--- Address 'T` <br /> k J Firm Partners,AddressAaa�4T lephone Numbers► Business Telephone No .Emergency Telephone No. <br /> Contractor Licence No. <br /> LApplicants.Name-(P in C��W RL i��,�r Title _ ate <br /> t Piease check Applicable Category(1-7)and Fill In the Required Information t4 <br /> 1-- ^PUMRER,VEHICLE,PERMIT-REGISTRATION(FOR EACH VEHICLE) <br /> For Julyz, June 30, 19 � Disposal Sites <br /> { <br /> Description-(Make/Yr.,Color) ) <br /> 1 Serial No. <br /> CAL. License No. _ - CAL. License Renewal No. <br /> _- - 3' ..s ✓'ri. " 'GaI.TWeightS"&"IvteaslTres`No- •-=�-•-= -•• - _._,,,.� <br /> Equiprrrfent Parking Address s <br /> 2. '❑ PUMPER YARD <br /> For July 1• June 30, 19 <br /> No.of Vehicles Stored- - >> r <br /> No.of Chemical.Toiiets Stored <br /> 3. ❑ PERCOLATION TEST ;~ <br /> R.S.or R.C.E.Name - <br /> r R.S.or R.b.E.No. r <br /> Test Location Test Date/Time " <br /> 4. ❑ SANITATION PE MIT t <br /> Job Address/Locationl�- _ <br /> Address t r� t <br /> SEPTIC TANK ❑ CESSPOOL LEACHING IF SEEPAGE PIT 0 PACKAGE PLANT 1✓ r y f <br /> PERMANE13NT TEMPORARY. �CNEWS "- ❑ ❑ t <br /> 's REPAIR pTHERr j <br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 t f <br /> Type Construction I _Disposal Site <br /> No.of Units _ Equipment Storage/Cleaning Location(s) <br /> - r' <br /> 6. 13 PA TREATMENTiPLANT For July 1,-June 30. 19 1 l '' `.1 <br /> .r <br /> Operator Name - - __- ' Where Certiflec[ t <br /> Plant-Location.- f <br /> Plant-Ca acit <br /> p y= No. Units Served i T <br /> 7. ❑.LAUNDRY .For July 1,-June-30,-19 SIZE:.h�E] Less Than 1,000 Sq. FMore,Than 1,000.Sq. Et;, } } <br /> DRY CLEANING,Chemicals UsedlAmounVMo. <br /> •4s,rr t <br /> 11dn�eow Grliesnsedeg.nt'saignsa,roeertNtesMeteRovrtng:'lcert'�ythat intheperformanceofthe work forwhichthis*permit isissued lshalfnotsir! <br /> M such manner as to become subject to workman's compensation laws of Caftfarnia.". , I I p t <br /> ContreCtefa 'Aldo os twbcornraeNng..Sipnatrtro cyr:,Ms•til!efluwfng.. I'certify that in the performance of the work for which this permit is IEsrisd,I she11 tV; <br /> 6utpl{ly petsAns sub�ect to workman s companseGof.laws of L_1tornia." �t,� <br /> - <br /> i <br /> `,•} I hereby certify l nave prepared t is application d that the work will be done in accordance with SanLoaquin Coiunty <br /> ordinances,stale laws, n <br /> ules nd r lati s o th an J uin seal Health District. t .k <br /> f <br /> APPLICANT'S SIGNATt7RE <br /> r f t I f t <br /> l <br /> : FOR DEPARTMENT USE ONLY <br /> Fee Is Due.❑ ANNUALLY ❑ PER UNIT ❑ PER SITE EACH January 1 h Received By January 31 ❑ July 1 8 Received By July 31 - <br /> XPL BILLING REMITTANC �,•! REMII <br /> IBAS�' EXPLANATION AMOUNT DUE )CHECKED <br /> DATE DAT M1VED ;AMOUNT <br /> FEE S T:�'j <br /> PRORATION r t ? i i <br /> PeUS }i i <br /> PENALTY <br /> OTHEH <br /> t n, I <br /> OTHER <br /> r +_ <br /> Received D _14,r ^Y'X( non <br /> Recei t No, / w <br /> y Dete P' j ^1 i ,Permit No..,.f . ' '} Issuance Date Mailed DeliVered y <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON.CA 93201 <br />