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Applications Will Be Pr sed When Submitted Properly Completed. Be fE11.01To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable, and Suspendable) „ <br /> ENVIRONMENTAL HEALT PERMIT <br /> LIQUID WASTE� � <br /> Ce Application is hereby made to carry on"Sie jurisdictio I area of the San Joaquin Local a Ith District llM A <br /> ,Zuci less Name (OBA) bOW 51M40bl <:114 X209 _- g/'�-1-7 Address�3.�AFZOF+iER ��4l 0AD���- <br /> i Owner MGS_MAVI-ARIET COR-NEE1=2uR Address <br /> 7 Firm Partners. Addresses and Telephone Numbers - <br /> Q. <br /> Business Telephone No. Emergency Telephone No. <br /> Contractor Licence No. <br /> Applicants Name (Print) - Title Date - <br /> Please check Applicable Category (1-7) and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19 -_ Disposal Sites <br /> Description(Make/Yr.,Color) — - - <br /> Serial No. CAL. License No. CAL. License Renewal No. <br /> Capacity Gal., Weights& Measures No. - <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored (zotil) 3(.9 - 4159 tf <br /> 3. 19 PERCOLATION TEST a.s$ MATTHEW QLAZA1t.0AI1CA. 7+SrZ'4.O f At`- �� <br /> 8:5=5-r R.C.E. Name WA�zre?- FC-UP-T 1 c "�f�r R. .E. N <br /> Test Location L INC1�Ct1 CR• Test Date/Time <br /> 4. ❑ SANITATION PERMIT r (5E.1=tr ISA&CEL 1Z�E�SE <br /> Job Address/Location ` 5111 OF <br /> co T <br /> Owner Address £ADIWCS <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER V <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 .�\) <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1,-June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. ( , <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. - \Y\►1 <br /> III;Iy� f y 11!s-41 <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws. <br /> APPLICANT'S SIGNATURE X � /� - �~-r-r d� Title Q CE 11 I�$CI Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 8 Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT OUE CHECKED <br /> DATE DATE REMITTED AMOUNT_ <br /> FEE a ! Z-9z //-i-5 t 7@.v�LESS <br /> ^9/ <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> b 5 <br /> Recwvfd by Date Receipt No. Permit No. laloance Date Mailed Deliveivd <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE..P.O.Boa 2009 STOCKTON.CA 95Na <br />