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Appllaat Ons WIN N Pie-MMM Whm od$N fad PtI"odN Oa11tPMll"d'M SIM To$I"TM Appl" M <br /> APPLICATION <br /> M _ (F ,ww"w"wwwft PAval ^Md SUOPOMON) SEPTAGE <br /> ENVjft0WnNTAL HEALTH PERMIT <br /> Low W"12 <br /> Applicati he; py made to carry on business to the judedictlonM at"of Win`•+sl J foal MNaH! t <br /> tlusMNs Name(CBA)_ � /�A lepSAI -- �' G• _—Add"�iTO <br /> Owner_ __ __ Address <br /> Firm Partners,Addresses and Telephone Numbers Emergency Telephone NO i <br /> f elneee Telephone No7"-7 <br /> T*LAPPNcartta Name(Print) -- - �r .-... 0!N <br /> PleMe~Applicable Category(1-T)awl FW N pa f ill"iMi1M f111S11AMIlrti <br /> 1. O PNMPER VEHICLE PERMIT REQIfiTRATIOII(MM ftAfrl M"" <br /> For Judy 1. June 30, 19 tIllomti owa <br /> pesel,40on(Make/Yr.,Color) _— _ C�►l. KIt Ltteb 111ftiwM ti0 r--- <br /> S"W No- _____ CAL Ltansa Ns. <br /> Cap" _-- Gtl.,tlyeiglTta•MeaeurN N0. <br /> Equipment Parking Address _ <br /> L ❑ PUMPER VARO <br /> For July 1• June 30. 19 _ _No.d VehkW Stored <br /> No.of Chemical Toilets Stored <br /> i O p N WLATION TEST P CX tib. <br /> R.B.or R Cff.Name <br /> ,� TMt DYMRMrIa ..1 <br /> L 1M%WNTAT'.ON PEIIMiT J" <br /> JoA AddtaMtloat+on <br /> doom <br /> Aeak.ae G �� 3 <br /> �'TfC TANK ❑ CESS�POO�-� ���� O It PIT <br /> 000 NT ❑ TEMPORARY <br /> L C] CHWXCAL TOILETS For July 1,-June 30,19 <br /> TW W W1a <br /> im __ Equlpmant swile"lC�/Lam) <br /> No.01 units ' <br /> S. C3 PACKAGE TREATMENT PLANT For July 1,•Jur4S0,tt) _ t�ltwt)f�wWEGII <br /> Operator Name — <br /> Plant Location __ -- <br /> Plant Capacity — - - - <br /> No.units 8arvad <br /> T. ❑ LAUPMY For July 1,-June 30, 19 <br /> SIZE: ❑ Lea Then 1,000 Sq Ft, ❑ More Than 1,000 Sq.Ft. <br /> ❑ DRY CLEANING,Chemicals Used/AnlounlMlo. <br /> f hereby certify that I haverepared this application and that the work will be done M accordance with San Joaquin County <br /> ordinances.state laws, les and ulatbns 1 the oaquln Local HNlth District. <br /> 4 APPLICANT'S SIGNATURE X --- <br /> +fir FOR OEMIITM UT USE ONLY <br /> FN b Dur.❑ ANNUALLY ❑ PER UNIT .P.�PER 1SIT_E 0 EACH f3 JMway 1 a I W0***d aY Janwry j1 0 May t a MOWh1 t1Y JULY J♦ <br /> REMIT <br /> RASE EXPIANA?ION a1LON0 REMITTANCE RCM TT[O AMOUNT OtIE C►+EAMOIIElTD ._. <br /> PATE DATE <br /> rE[ <br /> %ro AT,oN <br /> Mus <br /> A -i^—5e S/r <br /> PENAL TY l �A')"'7ia ^ <br />