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APP""Orle WW M Proo~sod WhM sUb"ted'r0P*dy C61111PMNd.M Sun To Sign The Appllcatfon. <br /> APPLICATION <br /> (For Non•TransiII rat-& I RewocaWe,and SMspardabM) <br /> ENVIRONMENTAL HEALTH PERMIT SE('iPi" <br /> ADPllcat+on LIQUID WUTE <br /> Mreby made to carry on business In the Jurisdictional area of the San osquln Local Health District <br /> OwneirMN&'Yw(DBA) _ Address-- �i l�,.i �v�OwnerFirm P Address <br /> ddreMss and TeMphwne re _ <br /> SU W 400 Telephone No. S�'t Emergency Telephone No.— <br /> zontraplor LION"No. "T-- <br /> ADPMCanb Name(Print) Title —T�. .•y-,� Date <br /> oleaee sheet AppNearb CaloSory(I• aTid pill la the 118400d IMwttiallen . <br /> 1' D PUNIMA YIN"Iff POWT 111111116ISTIIATION(POA EACH VEHICLE) <br /> For JULY I. Juno 30.19 Disposal sit" <br /> Deecnpt ni(Make/Yr.,Colo — — --�� <br /> Serial No. CAL.Lloonse No. —_--- CAL.Lloenea Rsrewal No <br /> apace _ Gal.,Welghts A Measures No. <br /> -QulpnlarM Paticlnp AddrMe---- — — <br /> L ❑ PUMPEII YARD - — — -- — <br /> 'or July 1, Jura 30.1g <br /> vo.of Velac1M Stored <br /> vo of Chemical Tolleb Skw" -- ----- <br /> I. ❑ Pt;IICOLATION TesT -- _—_— _—_-----_- — —I.S.or R.C.E.No R.S.or R.C.E.No. <br /> rest Location <br /> -.—_ Telt Date/Time- <br /> -1. 0 SANITATION PEIt>tifT tom. <br /> 'ob Address/Location <br /> )wrTer s71 =.Jalf.l:LRL� AddrMe_.---.-- <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD ❑ SEEPAGE PI�ACKA�G 1E�ANIT� ��� ' <br /> PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> ❑ CHEMICAL TOILETS For July 1,-June 30, 19______ <br /> rype 10r -------- _._ Disposal Silo <br /> No.of Units Equipment 8torsge/C11saning Location(s)-- <br /> M PACKAGE Tt1EATtt1ENT PLANT For July 1,•Juno 30.tg <br /> When CerUlled . <br /> 'last Location - <br /> 'lant <br /> C+Wc1b------- - _.-- _ _- _ No.Unita Served <br /> ❑ LAUNDRY for Juy,1.-June 30, 19 -- <br /> ;IZE. ❑ Lou Than 1,000 Sq.Ft., ❑ More Than 1,000 Sq. ft. <br /> DRY CLEANING,CMnwcais UIOWAmountIMO. <br /> M��arwb•�wlaewC•alY•+tun�rAAu•tlN Ic�•flr�rh.l �}hs�erla+rnsn�IMlhswnA�InrIrA�:bfWs aTHISInLucOlsh,�linol ---- --- <br /> in sxh m•nrxr..to:eat:r.; .swat i,,w.rh-...n'•,..�,�-E»�;�:�' 0 <br /> Cewtwato�• Arrine w wac-eu•et:o „• ~r., I M�ObYErlypre. <br /> �L+�dlw I,+w•ul��a41,1 I ww.w,.y. 1 ut+.lr IrW,n 1rlt perlorrn y;r.lt v4rA lar MMU,Il:n prrrtllt Is r+stMQ I s1U1) • <br /> Mnp10Y pefion�i�J;c„•i,aaA....,1� <br /> 1 hereby ceniy that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances,stats taws,and rules and rayulaiAnyEiGno oaquin Local Health District. <br /> PPLICANT'S SIGNATURE <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Fee If DW: 0 ANr+uwLLv----13 KR UNIT-T_Q PER SITE O EACH —0 .la"!Y 1 a Mq0 c« By J•MrMv 31 O July 1 E gKwwd 1►y Jwy 71 <br /> BASE EIiPIANAT1O1111 111"111111110REIMTTANCE E 11141111111T <br /> OATS REMiTTtID AMOUNT DUE PHECrfEO ' <br /> FEE AMOUNT <br /> --= <br /> LESS <br /> PRORATION ,I 7r` I <br /> PPLUNA <br /> ELTr <br /> OTHER <br /> ----------- <br /> -------- -------- ----r <br /> OTHER __ <br /> Hrcr..at7 br Lal- Hrc mpl Nu Pa,m,l Nu imus t•dew <br /> 11•.MO OM#-Vad <br /> APPLICANT-r1ETU11N ALL COPIES TO INVIIIONMENTAL HEALTH PInMIT,SInVICIg 1N1 a.NAULTOM Avg.P.0 a..30" ,eToclITorA 4 sew <br /> C{3 <br />