Laserfiche WebLink
(Pei NOR-TrrMMSOM.Revogeow nNMIspm) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID MADTE <br /> Application 1_rr�.pyr Ins[�syb,,u��rr—y oR p�slnss In try1�nsylponal srM of the San Joa ulnypC&I Health Dlstrlc}� <br /> r suMMN NYMIQJ—sL—/i�`a—�'�E' �C�f'f/i C��Cf Address 1'7A� a�0 AL�EL'�JEM� <br /> Ownew AALL�6�c/J - Addressi-/ds se ,�G1EL .107 <br /> firm Partners,Addresses end T <br /> DuaMlses TNephpts No. _ Emergency Telephone No. <br /> Carrsow Llarbe No. <br /> Appdooft Name Print) Awl Title — 7. Dae —/ <br /> Pres.hese A►pWb Cabgsey(1.7)and FN In Eta Required Information <br /> 1. O KMM VEINCIE PgMW REGISTRATION(FOR EACH VEHICLE) <br /> For July 1, .lugs 30.19 _._— Disposal Slles . Qo <br /> Description(MYWr..Color) O <br /> 80"NO. CAL.License No. CAL License Renewal No. C <br /> CApecry -._._ tial.,Weights a Measures No, <br /> EpWpment Plismg Address <br /> L D PUMPER TARO <br /> For July 1, Jur 30.19 <br /> No.of Vehicles Stored <br /> No.of Chem"Toren Stored <br /> L D PERCOLATION TEDT t a <br /> R.S.or R.C.E.era R.S.or R.C.E.NO. <br /> Test Location Test Date/Time_ tS <br /> A YR SANITATION PUrANT t <br /> Job e - \ <br /> e.P> Adores. <br /> jN SEPTIC TANK 13 CESSPOOL B LEACHING FIELD )IF SEEPAGE PIT D PACKAGE PLANT <br /> yr7 PERMANENT D TEMPORARY NEW D REPAIR D OTHER <br /> L D CHEMICAL TOILETS For July 1,-June 00, 19 <br /> Type Constructwn Disposal Site jjff <br /> No.of Units ___--__--_-- Equlpnlenl Storage/Clsaning Location(s) , <br /> is, O PACKAGE TREATMENT PLANT For July 1,-June 00, 19__ } <br /> Operator Name ___ _ _ ___— . . --- ---- Where Carutted <br /> Plant Location <br /> Pian,Capacity_ --_ _ No.Units Served -- <br /> 7. O LAUNDRY For July 1.-Junes 30. 19__-- <br /> SIZE. O Less Than 1,000 Sq. Ft.. D Mora Than 1,000 Sq.Ft. <br /> D DRY CLEANING.Ctre1711"A Ua111"/Amou111/11110. <br /> I <br /> I here" CMiy, that I have Prepared this application and that the work will be done in aixordanCa with San JOaqutn County <br /> and regu/lab�ons/of the San ern Local Health District. <br /> ordinsinces,state in".and� <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY -' <br /> i F«Is DORIC O ANNUALLY O PER UNIT O PER SITE 0 EACH ❑ January 1 a Rsrs.aa0 9Y janumY 31 O JVIy 1 a Racwaee By July 31 <br /> Ite BILLING REMITTANCE f REMIT <br /> SASEEXPLANATION DATE DATE TT D AMOUNT DUE CHECKED <br /> AMOUNT <br /> 4 5-D 0 . 4-5 D 0 <br /> l9 LESS — <br /> PRORATION A i _ <br /> vENAIn <br /> OTHER <br /> OTHER <br /> r 'Ti_ 4 fir.• �.e <br /> -7q <br /> '-?6'1 <br /> WCwrM nY D� r FK p Ne Mrm.I NP hNWKa DNA MaYp DNrvase <br /> Li T— ALL COMLe TD. ENVIRONMENT"� 'TN PERMITlSERVICES teat a.NAiELTON Aire..P.O.sae MOE STOCKYOrr.CA Hae` <br /> r� J/ <br />