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k Applleatlo s W111 Be Processed Whet SubmMed prupeMY CorllpMed.Be Sun To Sip The Appleatce• . <br /> APPLICATION ��_ <br /> +1 _ (For Non-TanN <br /> renble',Revoeabta,and Suspendabie) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> uQUID wAsTE ` <br /> r <br /> Applica is ne(et>y matle carryon busi as in e d ctfonai arae of th n Joa in local Health Diatr c hrJ�e <br /> Address. —T-�— <br /> Busin ame(DB ) <br /> 11 10 Art Address . <br /> Firm Partners, Addressee and also one mbar✓ Emergency 7elephorro No. - <br /> 9 Business Telephone No. - - <br /> Contractor Licence No. .. - Title <br /> L Applicants Name(Print) 1 . 'In <br /> IplssaetM�k_AjpNo�bk, 111(1-7.)and FM Rptrked <br /> + 1 ❑•PUMPER VEHICLE pEI�MIT REGiSTRATK)N(FOR EACH VEHICLE) f� <br /> 4 ' .'.a <br /> ✓) JU�16 90:,, =Dhposel Sites , <br /> For July'1'._ ;'' <br /> Dehc"f�lPtlifn(Makm1Yr.,Com,) l <br /> r �+Nd _CAL LI, No. CAL Litanse Renewal No. `. <br /> Serial No - 1 1" -I �-•n Gel.,Weights 8 Measures No. - /.. -•�J <br /> V'Cbpacdyr P• r M - <br /> Equlprllent Parking Address -- I <br /> p. ❑ PUMPER YARD <br /> For July l__!*une 30, 19 ) <br /> II of Vanities Slofld <br /> No.of Chalnlea]Tlets Stored . <br /> 13p'7rOLAT10N TEST R.S.or R.C.E.NO. <br /> R.S:or R.C-E Nart}yT Test Datw7ime <br /> ^feet L on <br /> �o�Et�� <br /> Vis`.ad SA;P;AYIQN PERMIT _ 1 <br /> Job Addr L tion _ AdCrese _ <br /> O ACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE <br /> P`.LANNTT <br /> I L�7�S PTIC TANK ❑ '���,�'t� ❑ PAIR <br /> IJJ'PER(YlANENI r 0 TEMPOFIARI r EW - <br /> r� <br /> 41cWaMICAL,"LET8 For JulyT:pJ�ne-x.19 <br /> A✓ type Cp atructfolJ 'J Disposal Site - <br /> 5 ' • No.of Units v Equipment Storage/Cleaning Location(s) <br /> T <br /> a. ❑ PACKAGE TREATMENT PLANT For Jgty`•-June 30,19 Where Certified <br /> I , <br /> Operator Name <br /> r-Plant'Loca9'O.rl <br /> ---.� No.Units Served 1 <br /> Plain Capacity- <br /> [3 <br /> apacity - i <br /> 7. ❑ LAUNDRJ',For July 1,-June 30.r.�19 f <br /> SIZE: ❑ Lyse T.14ynd,000 Sq.Ft., Laa(\M� ore Than l,QQII Sg.Ft- <br /> 0 DRY CLEANING.Ct>µlCals Used/A I1vivio. <br /> H ,� mfe`agPht+V3eamhsisl.Yt •t t thaf�ntkeperto:mance orthawink forwhhhthis psrmHis WuW.I shaft rtotemptoYanYP <br /> in wclrtyW aaio betiroGla�uSl ..ef6mi6 •n.:J:,CemsOnsaiJpr,;+�Ys of itore,: <br /> cenr aeloF's.rririP1_ree�0, s.. R.sr{ taco=�: dx't. n0: '1„w•JiY" •a the tlarlormance at the work for wiuca this Pont is issued.l9Wt .. S <br /> III ParsOnssuvtiict to.,?w .w�, St u�.�l:t'J �, <br /> r red thio app iCeuOO/and that thew - v ill be done in accordance with San Joaquin County <br /> I hereby ceRih',:that 1 he p he San Joaquin:Looel`Lleelth District. , <br /> ordinanom,state taws,a Tules an0 regu rN <br /> APPLICANT'S SIGNATURE •4j {rf's•+,,. �'� <br /> FOR DEPARTMENT USE ONLY <br /> ❑ J ry 1 a RaaauNd By JfrwerY 71 [3 my 1 a RPcei,ed D Juy 31 yv <br /> Fee M Dia: ANNUALLY t ❑ PEP UNIT (3 PER SITE ❑ EACH REMIT <br /> ' REMITTANCE AMOUNT DUE CHECKED <br /> EXPLANATION BILLING DATE• REM TTEO AMOUNT <br /> MSE - MITE Q6 L <br /> FEE <br /> -""SS <br /> ORATItNJ•"-� <br /> PPEENNAALTY yy ��--•-+ ../�> J J../.'- W f. �+� <br /> .. •Parma o. . Hua a b MAibd T hN <br /> Dal. 1•Iao. a1pCKTON,CA aa➢a1--f <br /> eceMPd <br /> by TAL NULTN PERaNTteellYidEa � 1p/E.NAiaLTON AYL P.O.am law <br /> APPLICANT-pETURM AL1.COPIES TO: e T <br />