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rt Completed.Be Sure To Sign The Application.
<br /> 'r ,t Apr!ications Wlfl Be Processed When Submitted Pro"I'll
<br /> APPLICATION
<br /> (For Non-Transfarebla,RswoCabN,and Suspandable)
<br /> tC ij
<br /> ENVIRONMENTAL LIQUID WASTE 7N PERMIT
<br /> nn a hereby made to carry on b si�ne+s;In the jurisdictional arra of the Sept Joaquinoca/y��Olstnct
<br /> rl� > ,S'O�IIJ Address /.e��.' ✓7TC'lr
<br /> p w BuSmess Na-, IgA,
<br /> i Owner Address
<br /> Firm Partners. Add ns•r•� +rid Telephone Numbers i
<br /> 1 F g Business Telephone No _. Emergency Telephone No
<br /> or—
<br /> Contractor Licence No .�- �+
<br /> Title L-� Date - - -- I
<br /> Applicants Name !Print) G�i/l.t1'G_ FL -
<br /> * t6
<br /> t ' Please check Applicable Category(1-7)end Fill In the R uhad Inlortnalron
<br /> rc; 1• ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) /1I
<br /> b*g For July 1, June 30, 19
<br /> Disposal Sites
<br /> Description(Mske/Yr,,Color)
<br /> � CAI.License Renewal No. --- -
<br /> +r Serial No CAL License No. _
<br /> Gal.,Weights b Measures No.
<br /> ,. Capacity - -- _ -----
<br /> Equipment Parking Address
<br /> 2. [:3 PUMPER YARD, -—- -----—
<br /> y, For July 1,-____- J.ine 30, 19
<br /> No.of Vehicles Stored _—_ •
<br /> No.of Chemical Toilets Stored --
<br /> 3. ❑ PERCOLATION TEST
<br /> R.S.or R.C.E.No. ----
<br /> R S.or R.C.E.Name
<br /> Test Location ----- - --- - - - Test Date/Time -- - --------
<br /> 7. ❑ SANITATION PERMIT'
<br /> Job Address/Location --
<br /> ", Owner49fCAddress ❑ PACKAGE PLANT
<br /> 18 SEPTIC TANK ❑ CESSPOOL ® LEACHING FIELD )W SEEPAGE PIT T -_`
<br /> 11 PERMANENT E3 TEMPORARY NEW Cl REPAIR ❑ OTHER N 1 YMW0
<br /> S. ❑ CHEMICAL TOILETS For July 1,-June 30,19__
<br /> Disposal Site
<br /> Type Construction _._. -- -------- - �+
<br /> - -.
<br /> No.of Units _ __ _ Equipment Storage/Cleaning Locations .,—_---- ---
<br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19—_—. Where Certified __-__--
<br /> Operator Name ----------
<br /> Plant location -_----- - --- ------------ ---
<br /> - -
<br /> f No.Units Served -- -------
<br /> Plant Capacity -
<br /> 7. ❑ LAUNDRY For July 1•-June 30, I9.__-
<br /> SIZE. ❑ More Than 1,000 Sq.Ft.
<br /> .r SIZE: ❑ Less Than 1.000 Sq. t., _
<br /> ❑ DRY CLEANING.Chemicals Used/Amount/Mo. r 9!
<br /> 01lof—. wN�w Nl br'n"d wow"",YyA•rrNA,rMrrfL'RHvww
<br /> ,140-r1 (r.T'1ffyyt$'f`t nPM�:aM.l ff /,1 til':YY,4.01,for vA-. 1this rVhilt is lsvmd.I r.hafl vot e' ,
<br /> m
<br /> h' yl vr' n•,•., �c,to bit'..JI•'""At`,.l fo Y,7,k,lran s(,r011r11',JIp;P I.rr,zj III cajdQHN.1
<br /> Cn.,rrwrrn:• Mrry w R„b u.nt.xeintl aplrrwn es.ntias 11w1 leila,w,iap. I ccri,!y lira!i,Ifte F4 of of the:,rori,for which 1110."Mit is issue.._..
<br /> a cupluy MvsMl w;4cct sa Yia�..nan s cncnpmsa; IAS of Cabtorcir
<br /> I hernhy cprt,fy that I have prepared this application and that the work will be done in accordance with San Joaquin County
<br /> f
<br /> ordinances.
<br /> state laws,and rules and regulations of the San Jos L I Health District.
<br />�y APPLICANT'S SIGNATURE X -- - -" -'-
<br /> FOR DEPARTMENT USE ONLY I
<br /> nwry 31 U July t a Rees we By July 31
<br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑EACH ❑ January 13 R REMIT
<br /> BASE EXPLANATION BILLING RF•MITTANCE AMOUNT DUE CHECKED
<br /> DATE DATE IT, D AMOUNT
<br /> _.._-
<br /> 1 _ /1
<br /> -
<br /> .. FEE
<br /> PROPATION
<br /> PLUS
<br /> � PENALTY
<br /> OTHER
<br /> n THFN 1 ...__._— _ �_--_--
<br />
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