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APPLICATIONr A <br /> )r Ndh•Transferable,Revocable,and Suspendal <br /> SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application is hereby made to car on business in the jurisdictional area of the San Joaquin Local Health Dis <br /> „Business Name (DBA)D J4 9A Q 1�1�1 5 4o"S,�_Address 120 • ©!C � Cly + ��Z 4D <br /> ?Owner Address -- -- -- <br /> Firm Partners, Addresses and Telephone Numbers <br /> iBusiness Telephone No. (a 91407 Emergency Telephone No. <br /> Contractor Licence No. — - - <br /> �ApplicantsName (Print) .Title _. Date � �1� �'� 1 <br /> Please check Applicable Category (1-7)and All,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) r <br /> Seriil No. J ' CAL. License No. CAL.License Renewal No. <br /> Capacity Gal.,,Weights & Measures No. <br /> Equipment Parking Address - <br /> 2. ❑ PUMPER VfRD'- ) <br /> For July 1, Jung 30, 19 i <br /> ..d <br /> No.of Vehicles Stored: <br /> No. of Chemical'TbiletirStored <br /> 3. ❑ PERCOLA19tibrEST , <br /> R.S.or R.C.E. Name f __ R.S.or R.C.E.No. <br /> _r <br /> Test,�,L,ocat��i n � ' Test Date/Time ' <br /> 4. W-61NITAI'10"NFEhMIT <br /> Job Addre s/Location IJML43 6 - aiJ4• ,&A) �ID1 <br /> Owner �' �"TZAIL Rip^b Adq )Jkq <br /> ❑ S.EPTIC TANK ❑ CESSPOOL erLEA(#hIING FIELD E SEEPAGE PIT ❑ PACKAGE PLANT <br /> 9-14E4MANENT ❑ TEMPORARY ❑ NEW B-1rEPAIR 2-MHER r_J-Se.-F 5 <br /> 5. ❑�,CHiMiCAL TOILETS For July 1,-Junib 30, 19 <br /> Type CopstrupidI04,14 -' Disposal Site ' <br /> No. of Vn its Equipment Storage/Cleaning Location(s) �s <br /> 6. ❑ PACKAGE TREATMEft NPL."T For July 1,-June 30, 19 <br /> Operator Name , —. Where Certified .� <br /> Plant Location` — "•- ` <br /> Plant Capacity-' No.Units SQ <br /> 7. ❑ LAUNDRY For July 1,-:June.30,49 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING, Chemicals Used/Amount/Mo. <br /> 4- <br /> 11 <br /> .( 11lereby certify that,li.Avqdpared th1 pplicatio d,the he w will be done in accordance with San Joaquin County <br /> orffinances,state laws r a Ion quin L- at Health District ' <br /> APPLICANT'S SIGNATURE <br /> 1!: F FOR DEPARTMENT USE ONLY <br /> Fee Is jdue: ❑ ANNUALLY =10 PER UNIT". ❑ P 17 �. �M ,I. p 1 aiv oa 1 [01iul�'16 ReceVVGO By July.31 <br /> 1 af1�L�NG R ANCE ->;5 RfrM1T <br /> RASE EXPLAN(1TIOK.. _ I 'w MOUNT DUE ( CHECKED <br /> <p. "'DJITE' _REmmecr - v AMOUNT <br /> O <br /> FEE fixI <br /> LESS <br /> PRORATION j .-.— 1 - <br /> PLUS �J p <br /> PENALTY 5 ;,,.7 1k UC.[ iA , 3r4 <br /> OTHER <br /> OTHER <br /> Ion <br /> Received by Date Receipt.No. Permit Nd '- �svau Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICESE..DJ).Bo[2109 STOCKTON,CA 95801 <br />