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r'1FlIJ114iI a1V 11� 8111 Aic rI V4CaaeM once.�UWIIll a lets r,V�ICI IF ar V111IJIC tie V•4'.��ylt e v,�Iyn Inc rapplwaawn. <br /> APVL`1 ATrb N <br /> r ?Non-Transte�r'�e�F evocable a'nd Sluspendabl <br /> SEPTAGE <br /> ENVIRON_ MEiVTAL HE_ALT_ H;PERMIT - <br /> LIQUID WASTE <br /> Application is hereby made to carryon business in the,jurisdictional area of th an,Joaquin Locai Hea Dlstrlcttd t <br /> F Business Name (DBA) .1 9A 1 fG Address <br /> z Owner ; Address. - -- <br /> a _,..-. . r _. �, ,.�. -- <br /> .0 <br /> ,,. . a <br /> Firm Partners,Addresses and�T lephhone Numbers <br /> CL BusinesseiehoneyNo *�y �'0.7 Emergency Telephone No: <br /> '- Contractor Licence No w �� <br /> L Applicants Name (Print) �_ S1A.�ryS' Y Title -STIh.1I7[91�°� Date �� +r <br /> ....y '..t ,. <br /> I Please check Applicable Category{i 7),;and;Fill;irl'_the Fiequiredrintorrnation.y„ ,,t; i;� I" n1s_fV A w ps. x.` ;; ti,i,.,,, -- <br /> i <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> _. <br /> June=30, <br /> pescnption(MakeNr Color) <br /> 'Serial No. CAL. License No. CAL. License Renewal No a <br /> Oapactty ° Gal„Weights&Measures No. <br /> Equipment Parking Address _ _ <br /> 2. © PUMPER YARD I <br /> -For July t1, a __�`-Jur)e 30 19 }. <br /> i <br /> No. of Viihicies Stored <br /> , <br /> -No. of Chemical Toilets Stored ¢ <br /> '3. 0`PERCOLATION-TEST.. ... .R.S. or R%C.E.`.Name i R,S.or R E.`No. <br /> Test Location_ Test Date/Time <br /> q- NITATION PERMIT <br /> Job Address/Location ly _ <br /> Owner fes” • CJs[/�I�LS Ad'dres`sCrA <br /> '❑ SEPTiIG TANK ❑"CESSI'O 91'CEACHING FIELDCEEPAGE PIT -❑ PACKAGE-PLANT -- - <br /> C'}tTRMANENT E TEMPORARY ❑:NEWOTH# @'REPAIR ❑ e <br /> �- <br /> ER w <br /> 5. El CHEMICAL TOILETS ForJuly 11 June'3&'19 ) 6' <br /> Type`Coi struction „,. :.� m 't + Disposal Site -r - <br /> I - A Q <br /> flo of Units I E�tiyiphient.Storage/Cleaning Locations} .. <br /> L a <br /> `, . <br /> 6 <br /> 6. P CKAGE REATMENT P.— <br /> LANT -FonUly i' June 30 19 <br /> Operator <br /> 7 , k <br /> _ z <br /> r "4 yyhere Certified - <br /> ' erator Nm <br /> ae-Plant Location <br /> Plant Caacity No Units Served , .. <br /> 7: ❑-LAUNDRYFor:luly `oun,;-30-19 f.. .,:1.zyy� ; <br /> ,❑ DRY TO <br /> Less Than-1,000 Sq! Ft ❑ Mor1ehan 100b Sq Ft <br /> o- ._ <br /> LEANING Chemicals Used/Amount/Mo` <br /> 1 Fiereb cer3if that I h ve re tired this a Ilcat' nd that the work Willi tie done in accordance With .7oaquin Ot unty - <br /> Y Y P P pp <br /> _ ordinances state laws _ d IJles and ulatio the oa in;:Locai Health District s <br /> k 7. <br /> APPLICXNT'S SIGNATURE <br /> yj <br /> , i - _ _ _ <br /> i <br /> DEPARTMENT USE ONLY <br /> Fee Is Due: ANNUALLY �_PER UNIT ❑ PER SITE ❑ EACH January 1 &Received By,January C!I�July 1 &Receeved ey Jul 31 <br /> -- ... '.. _.. - s y- -i 1 REMIT i <br /> y BILLING ! REMITTANCE AfQUNT DUE CHECKED i <br /> I BASE EXPLANATION <br /> a i - i- DATE, DATE REMITTED - AMOUNT <br /> l <br /> FFll <br /> FEE ....... <br /> 7T1 <br /> r PA6RATION <br /> PLUS <br /> PE ALTY h l - <br /> - : r <br /> � t <br /> AT#IER_ r { <br /> _ _ <br /> OTHER. -'-- - -`. ^tie -._ <br /> Ti �. <br /> Received'by n Date ,Receipt No' Permit No Issuanc OW �MtVW Delivered <br /> «_ <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT1SERVICES 1601 E.HA EL70N AYE.,PO. 6i 2009 STOCKT6N,CA 95261 <br />