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Applications Will Be Proce+sed When Submitted Properly Compietod.Be Sure To Sign The Application. <br /> APPUCA TI ON <br /> .� (For iron-Transterabte,Revocable,and Suspendabie) <br /> j ENVIRONMENTAL HEALTH PERMIT <br /> +; UQUID WASTE <br /> a Appltcauoe IS hereby male to ram on to In n the ur so tonal area of t san oaglw`� 0c, oalth District l <br /> t Busmes.Name(08A) M T k <br /> Address _. - ------ --- — <br /> Li' Owner sj_- Lx_ — <br /> �i i <br /> '• � Firm Partners,Addresses a^id Telephone Numbers _-_-_------------ -- - -'-`-" - <br /> h Emerenc Telephone No <br /> J �Business Telepr.one No. g Y — I <br /> — <br /> Contractor Licence No.s <br /> --— -- TWo ���{-`, <br /> Applicants Name;Print) <br /> Pteese check App;icab19 Category(1-7)and Fill In the Requwd Information1. L7 DUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) 1 <br /> For July 1. June 30. 19 -- --Disposal Sites ---- -- -- -- - ---- - - --� <br /> ,I Description(Make/Yr.,Color)—._ CAL.LSM - <br /> a' Sonat No. ---__-__ -.-CAL.License No. <br /> Capacity -_-- Gal.Weights 8 Measures No.-.---- — --- -- - - _ - <br /> Equipment Parking Address-__ - ---- <br /> -- - - - -- - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30.19 _. <br /> No.of Vehicles StOred <br /> tP!, <br /> No.of Chemical Tcllets Stored3. ❑ PERCOLATION TEST <br /> E R.S.or R.C. Name _ -_--- R.S.or R.C.E.No.Test Date/Time ------------- <br /> r Test Location ----- <br /> { { 4. ❑ SANITATION PERMIT - —_ <br /> Job Add 00 <br /> o0 �.,�--� r�_E_}� ��' -- — _-- - -- -- --- <br /> wnor 4' <br /> _t �� C - -• Adore"s _� - -- - -- - - -- r <br /> vt <br /> ❑ PACKAGE PLANT <br /> ('* �EPTIC TANK ❑CESSPOOL LEACHING FIELD SEEPAGE <br /> PIT ❑ OTHER <br /> 13 PERMANENT ❑ TEMPORARY NEW ❑ REPAIR <br /> • � S. �= CHEMICAL TOILETS For July 1,-June 30.19 <br /> R Type Construction - Disposal Site------------- _ - - - S,I <br /> No.of Umts Equipment Stora,-,0itr3ning Locatlontsl <br /> 6. G PACKAGE TREATMENT PLANT For July 1,-June 30. 19 Whero Certified _ <br /> Operator Name ----- --- - - - <br /> y Plant Locatior. --- ---- - - - - <br /> Plant Capacity No.Units Served — <br /> ` LAUNDRY For July 1,-June 30- 19--- <br /> ' , .a <br /> S:ZE: 13 Less Than 1.000 Sq.rt., ❑ More Than 1,.ta,Sq.Ft. <br /> ❑ DRY CLEANING,Chemicals UseWAmount/Mo. -- <br /> a' <br /> I hereby cert ty that I have prepereC this application and that the work will be done In accordance wl[n San Joagwn County <br /> A <br /> Ot hereby Cert-Y t d rules a reg '�LAnS O he Sa oaquin Local Health District. <br /> APPLICANT'S SIGNATU� - --. <br /> FOR DEPARTMENT USE ONLY <br /> }�',+`,,• r I IFN IS Dire; ANNUALLY ❑PEN UNIT -❑ PER SITE —G EACH J January t►Ro,:O,..,�)By danvwq r ^ �•ly 1 l RYcay.+I 9y July�I <br /> k —T---._.— ----r------ _�--REMIT <br /> �3 3ILLING REMITTAW $ AMOUNT DUE CHECKED I <br /> `.!,.. BASE EXPLANATION j DATE DATE RLMITTED AA40UNT <br /> FEE - <br /> r LESS <br /> PRORATION <br /> OTMEn <br /> ��` I PENALTY I �_ .___-__ ���_�-��� � ' • 1 J. �_-_ --. {—�- <br /> .�. . OTHER -- - -- <br /> dW <br /> NO IYOarK.1 Y WOM1YM�0 <br /> J <br /> RA��c ur jai a.MAZ[LTONAVL..I.O.M 3M iiTOC[TOK CA aur <br /> Y L� ARMLICANT—NETURN ALL GOPILS TO Ill"ll i1[NTAL HEALTH PERYITIeERVIC(S <br /> is <br /> .M S <br />