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i <br /> Af PLICA T IU€Al <br /> (For Non-Tfonmterai/le•Revacable,And Suspendable) <br /> Et4VIRONMENTAL HEALTH PERMIT <br /> IIQUID WASTE <br /> Appiwarlon is herety made to carry an business In the jurisdictional area of the San Joaquin Local Health District <br /> MBusiness Namn +Dt3A) Y),�^, f1A.1",�"-Cev >sr'!--A''s •-.-- . - Address fH Reck /y11"7',-. s'rr.✓- 5�S.7t'/_ -___ ._._ <br /> Owner Address <br /> 'ti u Firm Partners. Addre9gt-s and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No. ---- <br /> Contractor Licence No. -__ '2 S., <br /> M ve-S--___ Title .E5.r"i.�ri►TD�__•.__-_ Date ._/0-_X_71►—.--- <br /> L AppiiCanis Name(Prmtti --.__..Fr�y�4.__J_. .,...._............,_. . ._ <br /> Please check Applicable Category(1-7)and fill In the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGIST-IATION(FOR EACH VEHICLE) <br /> For July t,.-_....__.__.-.June 30, 19 _ _ Disposal Sites —_�._ --._—_ ____-------_ _ ...-____--_.-- <br /> . <br /> Serial No. .�.__._...._ _. CAL.License No. _..--_ CAL.License Renewal No. <br /> Capacity _. .. Gal.,Weights Measures No. <br /> Equipment Parking Address --..•-_-- _ _ --,----.._ _... V_ - -- _— <br /> Z ❑ PUMPER YARD <br /> For July 1,_ -- June 30. 19 <br /> No.of Vehicles Stored <br /> No.of Chemical Toilets Stored. s, � -..-,.--------- <br /> 8. ❑ PERCOLATION TEST <br /> R.','.or R.G.E.Nn mo R.S.or R.G.E.'Nb <br /> Test Location . ...-- _ _.___.._ __W_ _.__- Tent Date/Time <br /> A. JR SANITATION PERMIT <br /> Job Address'Locatlnrl ;� /_ cA�r/EPA 2 n, ._ -S7aC-K fl*.•}J __.. �_ _ . _ - - - <br /> Owner _P. Ir ' caw r>_'v __. ___ Address ..I�Q_am`t-7,(*.frr ,-_5.re Cot reov,C4.._..7'ts-0."7 <br /> SEPTIC TANK ❑ CESSPOOL LEACHING FIELD A SEEPAGE PIT ❑ PACKAGE PLANT <br /> 11PERMANENT ❑ TEMPORARY NEW ❑ REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1.-June 30, 19 <br /> Type Construction._.._...___ .....__--- ---Disposal Site <br /> No. of Units .. .-_ Equipment Storage/Cleening Localion(s) <br /> G. ❑ 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. 14 - -N __«.__., _._ -- . ._-_.. _—_-• <br /> SIZE: ❑ Less Than 1,000 Sq Ft., ❑ More Than 1,000 3q. Ft. <br /> ❑ DRY CLEANING.Chemicals Usnd/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done to aceordanne with Son Joaquin Counly <br /> ordin,at r:es. stole laws. ind rules and regulations of the o'Iquln Local Health District. <br /> APPLICANT'S SICNATLFRE X <br /> FOR DEPARTMENT USE ONLY { <br /> Fee to Due: ❑ ANNIJAL%-Y ❑ PEA UNIT- K PER RITE ❑ EACH ❑ JAnva v 1 A Received By JApuAry 31 ❑July'A Rece'w•d By July 31 i <br /> REMIT <br /> - RAST EXPLANATION BILLING REMITTANCE S AMOUNT DUE CHECKED <br /> rIrMITTED _ AMOUNT <br /> FEE_—_.. .... .�.!S�.- __t_.......V--,. ....._.._. .—_._....f.._......_.. �_..._._ - - <br /> LESS <br /> PLUS <br /> PENALTY , I l <br /> OTHER <br /> -_._ <br /> OTHER <br /> HeCe;ven by _ DAIw '�"geceiphNa emit No Issua:, a" IeQ-- 0401- <br /> APPLICANT—RETURN <br /> !APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PEAMIT/BE4VtC6a 1001 L.NAYLLTON AVL.,P.O,ae.70M aTOC TON.CA fS1U1- <br />