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Applications Will Be Processed When Submitted Properly Completed.Be sure 1 o 01y r <br /> APPLICATION <br /> (For Non-Transferable;RQYOJaDIE,and Suspendable) SEPTJ>GE <br /> ENVIRONMENTAL HEALTH-PERMIT <br /> LIQUID WASTE <br /> `A pllcation i r y ma t c r on b iness in the jurisdictional area of the SanJJo �ir� alXHpOth"Di <br /> Address <br /> Business Nam <br /> l� Address _ <br /> Owner _ 1 <br /> Firm Partne ,Addresses and T I Eon bers Emergency Telephone No.: _ <br /> $ BusineseTelephone•No. - -��— <br /> Contractor Licence No. - - _ - <br /> .Title - pate <br /> t Applicant`Tlame (Print) m 'r t• <br /> Please check Applicable Category 1-7)and, I,in•the Required Information � ; , - �ib6 -,xj :!.: 3• �} <br /> 1. ❑ PI IMP-ER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) P t <br /> :r� - Disposal Sites-,' _ = <br /> for July 1i. JUhe 30, 19'-- 1A j yI) 6"1 t _,) t - <br /> Descript bb JMake/Yr.,Color) A r- r <-Serial No.No. <br /> CAL. License No. 'kCAL.iL'ibMse'Ren��l Nb• <br /> Capacity Gal.,Weights Measures No. <br /> 1 i <br /> Equipment Parking Address <br /> J.1 <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> -No,of Vehicles Stored -•^^"" <br /> No. of Chemical Toilets Stored <br /> l 3. ❑ PERCOLATION TEST <br /> R.S.or R.C.E.No. _. <br /> R.S.or R.C.E. Name (1 <br /> Test Lo Test DatelTime <br /> �� . <br /> 4. VSANITATION PERMIT <br /> Job Addre ocat' <br /> Address <br /> Owner HING FIELD SEEPAGE PIT L[�-ppCKx1GE-PL'ANT-" -"" <br /> L'4 EPT{C TANK ❑ C POOL ❑ REPAIR ❑ OTHER <br /> •❑ PERMANENT TEMPORARY NEW 1 <br /> L s. ❑ CHEMICAL TOILETS For July 1,-June 30, 19 • � <br /> Type Construction Disposal Site <br /> Tip.of Uriits Equipment Storage/Cleaning Location(s)V <br /> fig_ ❑ PACKAGE TREATMENT PLANT For July 1,-June 30,19 Where Certified <br /> I Operator Name <br /> Plant Location _ }. <br /> W1ant Capacity <br /> T No.Units Served <br /> 7. ❑ LAUNDRY For July 1,-'June 30, 19 y <br /> { <br /> �S ❑ More Than 1,000 Sq. Ft. <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., - i <br /> DRY CLEANING,Chemicals Used/Amount/Mo. _ <br /> r <br /> hereby certify that I have prepared this application and that the wolrk will be done in accordance with San oaquin County <br /> I1 <br /> L., 2 4 <br /> t _ ordinances,state laws,and r nd regulatio s of the an Joaquin Loca(Health District. <br /> t 1. _ <br /> APPLICANT'S SIGN_ATURE X k I!' Pr- �- / <br /> FOR DEPARTMENT JSE ONLY <br /> Fee IS DUe: ❑ ANNUALLY ❑ PER UNITY ❑ PER SITE ❑ EACH January 1 fl Received By January 31 [I Joy 1 8 ReceivedREMIT <br /> uIy 3t <br /> .BILLING -RE MITTANCE AMOUNT DUE CHECKED <br /> BASE E%PLANA;ION DATE ATE RE D - AMOUNT <br /> FEE f <br /> i 11 <br /> LESS 1 <br /> PRORATION• <br /> PLUS <br /> PFNALTY <br /> OTHER I•. ._.« �..�•'( "'1 5 .,� %�i 1. p V '+ 1 <br /> OTHER - <br /> { \+ I a e D a Mailed Delivered <br /> Permit No. 1,�.T <br /> Received by Date Receipt No. <br /> "1991 E NAZErLTO AVE,P.O.PE Bor 3009 8TON. -9*aRiSt'�" <br /> ` �pPPLICANT—RETURN AL—OPIEt TO' EN I1IROMMENTAL MEALTH�RNIT/SERVICE 1 �,/� <br />