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<br /> Applications Will De Processed When Submitted 1'roperiv Completed.Be-sure To Sign The Appilcaflon.
<br /> APPLICATION
<br /> (For Non-Tranaf@rable,Hevocable,and Suspendable) y
<br /> ENVIRONMENTAL HEALTH PERMIT SEEPAGE
<br /> <: LIQUID WASTE
<br /> ( Apprlcation is reby m,•de Carry on�smess in the risdictionai area ol'he n o Irt Local alt �sfrict 1v
<br /> Business Name(DBA) _ 1.7 _�fr?�t,GI�Zp*�C�L ACdreat_/
<br /> Owner —_ Adt:ress
<br /> y.
<br /> $!=irrt partners,Addresses and ielepho a Numbers
<br /> Rus!ness Telephone No. — 6 Qz — cs
<br /> Emergency Telephony,No. +:'"� s,
<br /> ;Contractor Licence No._, — r' - - •.,K_;;,,,.��e
<br /> L Applicants Name(Print) r __Title Osla y
<br /> Please check imollcoble Category(1-7)and Fill In the Required Information
<br /> I. C3 PUMPER VEHICLE PERMIT REGISTRATION(FOfi EACH VEHICLE) >!'
<br /> For July 1,-,- June 30, 19 Disposal Sites
<br /> Description(Make/Yr.,Cn!or;
<br /> Serial No. CAL.License"!o.- _ _CAL.Llnerltie Renewal No. -
<br /> Capacity Gal..Weights&Measures No.
<br /> Equipmeot Parking Address
<br /> 2.' ❑ PUMPER YARD
<br /> ForJuly 1, June 30,19
<br /> No.of V&hicles Stored
<br /> t? r
<br /> No,of Chemical Toilets Stored r "•ani Z
<br /> 3. ❑ PERCOLATION TEST
<br /> t R.S.or R.C.E.Name R.S.or R.C.E.No.
<br /> $' /
<br /> Te c!(ion Test Date/Time.
<br /> 4. SANITATION kRMITt
<br /> 'Job Address/ oc tio _s�
<br /> Owner I-FE VJIAS ,!t/C_ Addi ass
<br /> 1 ❑ SEPTIC TANK ❑ CESS JOOL r❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT u l +'a
<br /> s ❑ P.ERMAP ENT" ❑ TEMPORARY ' � ❑ NEW
<br /> a - >I%H PAIR
<br /> n�j ati'
<br /> OTHER O1I�.BF.�
<br /> 5 ❑ CHFMICAL T'011. TS: For Juiy It,=June 30,-19 " .•wr
<br /> 17
<br /> Type Coriativetlon r• Disposal Site .
<br /> No.of Uriits ) Storage./Cleaning
<br /> ' Equ)pment Location(s) f 1�` Fq . `r.� ,•�: -
<br /> 8
<br /> ,P CKAGE;TREATMENT I-LANT For July 1,-Jun6,80,19
<br /> OratorfNeme ,Where Certfied 1 1�}• i y
<br /> Pians Locatlort-
<br /> Plant CapacityiN }7rk.
<br /> No U_nrts Sen ed
<br /> r n 7 ❑ LAUNDRY •Fcr July 1 June 30,19_ _. _ !+
<br /> t SIZE: ❑ Lessjhan 1,000 Sq.Ft., ❑ More Than 1,000 Sq.Ft. - xJ '
<br /> ❑ DRY CLEANING,Chemlcdrs Used/AmounL'Md. Al
<br /> xu.rtt stns ^
<br /> t T✓
<br /> (hbrepy certlh�,that l have prepared ,his application and that the work will be done in accordance with San Joaquin County.,i y
<br /> bfriindrfees stg'A laws,and rula d regulation of the S o gain L ;z. Health Distr ct.
<br /> APPLIC j rSSIGPiXTUR•EX\4y_ >hf �k'1•? /T " .
<br /> � 1
<br /> -:FOR DEPARTMENTUSE ONLY
<br /> Fee Is Due:❑ ANNUALLY f [ 7
<br /> ❑PER UNIT ❑PER SITE _❑EACH ❑January 1 A Received 8y January 3t. ❑July 1 8 Received BYjuyST ,
<br /> BASE EXPLANATION •BILLING REMITTANCE i
<br /> -MEM
<br /> DATE AMOUNT DUE CHECKED'
<br /> DATE REMITTED 1•
<br /> FEE - .� t:_ �� ` .� _A �,, ..r.�•,p ;.
<br /> L. . LESSATION
<br /> .
<br /> Ao1.c Ise; i
<br /> ;'.PLUS L �n
<br /> PENALTY - - - % �. •• Au
<br /> _ ` F•3 f i,.,l rr fru{
<br /> OTHER - '� '` { -t"v h►,
<br /> ;.OTHER
<br /> eec i!v;d by -T—
<br /> Date Recalpt No. Permn No. - uWn tor I ^�: .•1,;'
<br /> a-- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICE! !/E01 E.HA2ElTON AVC-P. ea 7QQE, ��
<br /> - _ a1.00KTON,CA @SE01 ✓Jc
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