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Ar,P11CNlon!Will Se P•oceesed When Submitted Property Corllple/ed Se fun To SWO The APP11Ce6ws. tJ <br /> APPLICATION <br /> (For Non•TnmterebN.Reeoceble,end Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> o rreby mnaaddp caarrrjybn bu�s In rI'a 1 4bonal area of Ino San Joaouin localHMlstDsN1LT <br /> ADDlicati <br /> „Business Neme IDBAI urG/ i Address - - — "-- <br /> Addreta <br /> i Owner <br /> 4 Pim Partners Address"an 1 non Nur`�b'pn • <br /> a Bu:mess Telephone No � �^ -Emerpencv T•Np110oM NO.Contractor Licence No <br /> -.— —�'e•_ ---=A <br /> ApplicantsNeme (Pr,, r Title <br /> dew <br /> 1 <br /> Plesse check APPIICebte Celepory(1'7)end Fill M the Required Inlof"WUOA <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE) <br /> For July 1. .. _ June 00. 19 Depose,Sites <br /> Description(Melq/Yr.,CNorl - -- -- !-_ <br /> CAL.LIlM1N ReneMM No. <br /> Serial NJ. ___ CAL Licen"No <br /> Caosclty _- _ Gel..Weights 6 Measures No - <br /> E9WpmsntPerking Address ___ _._.. <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 70 19 <br /> No Cl Vehicles Stored ---- -- ---- —' <br /> No of Chemical Totals Stared - — _ - <br /> 3. ❑ PERCOLATION TEST R S or R GE-No --AS or R.C.E. Name <br /> Test Locallon Tett Dale'Tme . - '— <br /> e. ❑ SANITATION PER /O��� /� ,/ ( •_ 1 _ _.- <br /> JobAp Locati � wl Ay6I1� -_ <br /> own I NJ"Je_ .. _ ddreYr��� 1 <br /> ❑ TIC TANK ❑ CESSPOOL 113 LEACHING FIELD M'VrEPAGE PIT ❑ PACKAgE PLANT <br /> GY6ERMANENT ❑ TEMPORARY O�W 0 REPAIR ❑ OTHER <br /> S. ❑ CHEMICAL TOILETS For July 1. .June 30. 12 C <br /> Type Construction Disposal Slle <br /> No of Units EOulpment Slor 1p/CleAriing Lotationp) 1 J <br /> S. ❑ PACKAGE TREATMENT PUNT For July 1. -June 00, 19 1 C <br /> WM•ti Certified - <br /> Operator Name <br /> Plan' Location <br /> Plant Capacity No Umts Served <br /> 7. ❑ LAUNDRY For July I -June 00. 19 <br /> SIZE ❑ Less Than 1 000 Sp Ft. ❑ More Than 1 000 S17 Ft y-- - — <br /> ❑ CRY CLEANING.Chemicals Used'Amount,Mo <br /> ►� Il r� eZs'x � J-.lao,r-�� 7e <br /> I hereby certify that 1 have pr re I •pDlicahnn a he won *,it be-done in accd' ne7'"w'/KSS4 h+•9u^I ^1y <br /> ordinances. state 1•ws. and ru • regulation .an J-r LM41 Hill D.stnct r <br /> APPLICANT ! - <br /> J a ,s <br /> OR DEPARTMENT IIE!OMIt ' <br /> Fee to Dur. ❑ .•.. I]is R i Mn ❑Is n•.m 0 f al.. O ,A n.r....•e Nr Ire..•. I. ai.h l e w.ae..'Rkwr ,'�• <br /> nu nN., ••r wf•AfecL f Awlnr lr'" tsr[e•to <br /> i.. i l.li•NtiNM nen nerL of M1l lin _•aSpI1N1 <br /> ., .v .r r. ..•... rnr.n.n INaen..rrNLl wUIrN VIRMIf RRnCfS .WSl lWeetfCl•aW Poee.Jla. e.00•.MI Ca Mme• ' <br />