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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> (For Non-Transferable, Revocable,and Suspendable) SEPTA.G7 / <br /> :ENVIRONMENTAL HEALTH PERMIT A <br /> i <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the jurisdictional area of the San Joaquin Local Health District <br /> F Business Name (DBA) - Address 1295 N Emerald Modesto 5351 <br /> a Owner Thomas Rampoldi Address CV0Cit1 S. Van Allen Rd. Stockton 95206 <br /> Firm Partners, Addresses and Telephone Numbers (209) 754-3588 <br /> a. Business Telephone No. (2109) 754-3588 Emergency Telephone No. (209) 527-4940 <br /> -Contractor Licence No.NA Engineering-Testing Inspection Firm <br /> Applicants Name (Print) QCI By Jess Wry Title P.E. Employee Date 4/24/91 <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 <br /> 3. & PERCOLATION TEST <br /> R.S. or R.C.E. Name QuAlity Control Tncnect i on R.S. or R.C.E. No. M 91-17 <br /> Test Location See Mip Test Date/Time 4125191 <br /> 4. ❑ SANITATION PERMIT <br /> Job Address/Location <br /> Owner Address <br /> ❑ SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT <br /> ❑ PERMANENT ❑ TEMPORARY ❑ NEW ❑ REPAIR ❑ OTHER <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. <br /> Home ownwor licensed agent's signature certifies the following:"I certify Ihpt 4a the performance of the work for which this permit is issued,t shall not employ any person <br /> in such manner as to become subject to workman's compensation;!ae✓s of Calits:r:,. <br /> Contractor's hiring or sub-contracting signature certifies thu iollovAris: 't certify that is the pettormance of the work for which this permit is issued.I shall <br /> employ persons subject to workman's compensation laws of California." <br /> I hereby certify that I ve repared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state la and r les a d re lations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X <br /> Jess Wr P.E. <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BILLING REMITTANCE $ REMIT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> �/ 42-4. AMOUNT <br /> FEE 4'11/4 0-0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> E791 S-1 <br /> Receiv Date Receipt Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.MAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />