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-- n APPLICATION CYr V- <br /> (Fo, Non-Transferable, Revocable, and Suspendable) ` <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE IV/ <br /> Applicatiar�is hereby a to carry on bussness in the jurisdictional area of the San Joaquin al Hea DSS ct <br /> less dame ( B ) -cv �� <br /> /7t� _ Address /1�j <br /> e �/ Address — S <br /> Partners, Addresses and Telephone Numbers <br /> Telephone <br /> -act Emergency Telephone No. <br /> -actor Licence No. <br /> .S� �J i <br /> ocants Name (Print) rj f-t <br /> � _--- Title —�� Date <br /> se check Applicable Category (1-7) and Fill in the Require Information <br /> PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) r� <br /> v •- <br /> JulY 1, .June 30, 19 Disposal Sites <br /> ription(Make/Yr., Color) <br /> No. CAL. License No. CAL,. License Renewal No. <br /> :city Gal., Weights & Measures No. <br /> oment Parking Address <br /> PUMPER YARD <br /> ilY 1• June 30, 19 <br /> Vehicles Stored C <br /> Chemical Toilets Stored <br /> PERCOLATION TEST <br /> R.C.E. Name R-S. or R.C.E. No. <br /> -)cation <br /> _ Test Date/Time <br /> SANITATION PERMIT <br /> �- <br /> :res Location G r L{�1� - �— <br /> ~ !YJ'L-�Ji-rr f1T Address s Gk's <br /> TIC TANK ❑ CESSPOOL FIELDSEE?AGE PIT ❑ PACKAGE PLANT <br /> ?MANENT ❑ TEMPORARY ❑ NEW REPAIR ❑ OTHER a <br /> CHEMICAL TOILETS For July 1, -June 30, 19 <br /> .onstruction Disposal Site <br /> Uri is Equipment Storage/Cleaning Location(s) <br /> PACKAGE TREATMENT PLANT For July 1, -June 30, 19 �► <br /> )r Name Where Certified <br /> kation <br /> anacity No. Units Served <br /> AUNDRY For July 1, -June 30, 19 j <br /> ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> CLEANING, Chemicals Used/Amount/Mo. ; <br /> I hereby certify that I h ed this application and that the work will be done in accordance with San Joaquin County ' f <br /> ordinances. state laws and ru Q regulations ofttm San Joa uin Local Health District. <br /> ANT'S SIGNATURE X •C� <br /> r�r FOR DEPARTMENT USE ONLY <br /> to Is Dues ❑ ANNUALLY ❑ PER UNIT v_.r PER SfTE ❑ EACH <br /> ❑ January t&Received By January 37 ID July l 8 Recervad By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE ; REMIT <br /> DATE DATE REMITTED OUNT DUE CHECKED <br /> 41 AMOUNT <br /> 33 <br /> ORATION <br /> US <br /> MALTY i <br /> SEA <br /> �C <br /> "HER 9 <br /> celved by Date <br /> R¢CP.Ipt NO. <br /> _ 1 <br />