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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign 1 ne Appecanon" <br /> APPLICATION <br /> a <br /> / _ to ✓ I/� (For Non-Transferable,Revocable;and SuspentlabM) $EPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT a <br /> LIQUID WASTE <br /> f�/� -s�y . . <br /> Appli n is tZererb m to try usin the i sdictional area oft J "iuin Deal H alth <br /> Address <br /> Eusin time (08 - — <br /> ie Address <br /> iOw r _ ' <br /> 9Flrm Partners. Addresses and Telephone N u � <br /> Emergency Telephone No. <br /> aBusiness Telephone No: <br /> y Contractor Licence No. Ii tie. 0 <br /> Date <br /> i-Apph2agt5.Nahne_(PrinI) . 1 <br /> please etwek APPileable C ry(1-7)and Fill in squired Information <br /> t. r Y <br /> (1.),�•py�p��Ha1�CLE.PERMkT�9E615T,RATION(FOR EACH VEHICLE) <br /> For July _1cu.t� �.E1���` Disposal Sites <br /> Descriptign jMak3/yr:,�aALM') "..._ CAL. License Renewal NO. Rt <br /> Serial No. J\ CAL.License NO. t <br /> Capacity `r`3' Gal.,Weights 8 Measures No. <br /> Equipment Parking Address <br /> 2 ❑ PUMPER YARD <br /> For July 1, June 30,19 1 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST R.S.or R.C.E.No. _ f <br /> R.S.or FLIStE Nyhe - <br /> Test location Teat Date/Til11e <br /> a. ❑ SAN ITAT)ON PERM TT Y- <br /> Job Add Lo�ati <br /> Ow r • ' : Address lZ�.- t <br /> ❑ CESSPOOL LEACHING FIELD LJSEEPAGE PIT ❑ PGKAGE PLANT t <br /> !7 SEP JC K <br /> iRANEN7� 13TEMPORARY ❑ NEW 'REPAIR <br /> 6, ❑-CHEMIGAL TOILETS For.�UIY 1,-June 30. 19 <br /> Type Construction f Disposal Site f ro <br /> No. of Udits I1 - Equipment Storage/Cleaning Location(s) C/ <br /> 6. 13bd(ijP TREATMEItIF PLANT For July 1,-June 30, 19 .where Certified ) <br /> Operator- <br /> Plant Lo ion ( I <br /> e1 1 No.Units Served <br /> C¢ 1 <br /> Plant puity'- <br /> 7. ❑ IfILIJNDhV For,.401y 1pttne-30r 19 i t,fr <br /> SIZE. ;0i Less`Tan4,000 Sq. Ft., ❑ More Than 1,000 Sq.Ft. ;}} <br /> 1 f <br /> ❑ DRY CLEANING,Chemicals t'Jaed/fmounV fMfo. , <br /> Ngmownerer6esesetl naent'EdaM'ryne<e>tiftEstMfogowity:9 Mrt(ryNthalinfMperformamofthewark fm wtlicathrs aermR lsissulM.I shaAnotempby aaypenon <br /> in such Maine[- to become sultan 13 w3warfs tompen<ation laws of Ca libmia" <br /> ccoHRraela/a furNy r sub-ep�nxrinp -Mann .e cerlNgs 1M-foaovMM: "I chraly!a::'1:t Jhe perler!nan"of the work for which this ocmil AS 1swe�J,l shall <br /> 7erseno 3usleoi b'a,.atrt...^.'o compreat 01I laws ut Cafi:u:ria. t t <br /> i%.-s 1 <br /> I heteby certity that 7 h e prepared this application and that the work will be done in accordance with San Joaq unfy <br /> ordlnanLe,state lawh, a _ lea anlQ.r stion f the San Joaquin Local Health District. <br /> ITT1J,�/�i��--�2� t <br /> APPLICANTSSIGNATURE)( --�. <br /> FOR DEPARTMENT USE ONLY <br /> Fu Is Due: C7 uALLr ❑PER UNIT PER SITE EACH ❑ January 1 8 ReraN/G ElyJanuary 31 ❑JuIt 1 a Raxiv REL1.ITulY 3t <br /> S`y,� EXMNATION <br /> BILLING REMITTANCE a AMOUNT DUE '�CHECKED <br /> dA <br /> SE DATE DATE REMITTED { AMOU <br /> FEE 1 <br /> LESS <br /> ROORATION <br /> 1W <br /> PENALTY PLUG <br /> rENAIn Qom. <br /> OTHER ' t <br /> OTHER <br /> Asrelva0 tW aM - Reo ilit Nal Permit No. I an<e Ms Marim DMWereO <br /> APPLKANT—a[YINN ALL COPIES TO: 1 ENVIRONMaNTAI HEALTH Pi"u"IT/SERVICEt:� 10aE aTOORTON•CA NEW E.NAZELTON AVE..P.O.aw <br />