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<br /> ApPlicallono Will ue Processed When Submitted Prapadl Compleled Be Sure To Slpn The Applteatlon.#
<br /> APPLICATION +r� ,
<br /> [For Non-Transffrable,rflfYotablf,and SuaPfndSblf) ix �'
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<br /> ENVIRONMENTAi. HEALTHPERMIT /, 'I ,,SEFPIT
<br /> ,i1 LI`ulo wASTEyttiY err a Cb 0
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<br /> Application is hereby made to,;arry on burinQQ n the(urisdictional area of the Sa uln Lp al Health Des ric t '
<br /> a Bus nes9`Narrte'�IDBA} MCT3onaZd,irSatn)r MTan�c�ServicepWx,Addreas"��h z���+� H>�dreth��:ana l .
<br /> rA IY"r! T !F. iC�onB�d " AddressFrmPaitners Addresses and Tele nope Numbers' {'e p10&V�Ane
<br /> a�,rR Af31 �Orf97 ,} ! r k 957_. 02'7
<br /> Business Telephone No O Emer enc Tero hone No
<br /> .Contractor,Licence NOD'+'`
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<br /> L�Applicants Nama(Prinry• `' �� Title
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<br /> Please check Appilcable Category.11-7).and Fill in the Rfquired Inforreallo»
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<br /> 1 ❑ LIMPER•VENIGLE PERgAIT REGISTR'ATION{FOR EACAIVEHICLE� s �f
<br /> Fo Jit y June 3019y �n� 4 DlsPasal Sifes k d' ` k + tit
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<br /> escrlpt 4n(Make�fr Gvlor►�l,_z
<br /> tW' 4t; ;r r +.,,. ,r, °• ''CAL:Lleenae No. CAL.License Renewal
<br /> Seriall
<br /> kyv:Cak' O fa r+}+!f'
<br /> ac ty `� } v Gat Weights 6 Measures ND
<br /> Eq iipmenzParkri Address
<br /> f pf P A,' i.+• i {�i F� P ,v M f �r,'t' Sa` d "sY t
<br /> ❑'(tP�IMERLYARD
<br /> •F l 'Fc�rvEll !� tr i 7:r y f t -S 7 �'i t d 't t
<br /> FOr
<br /> No of llehiolestl'Storedry# lg
<br /> N4 of:C emIdal:To(letd'SIored
<br /> 9 C3'PERCOLATION TEST,-10-.a dE r fi �
<br /> 0 R.C�S:-N"ams s t 's .J'lnL"J�aCju,r��"+�.,.,. .s .,;: is ,4.,R.S
<br /> T St Ltbbcation .' a k a E Tr39t Date/Time
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<br /> 4 1;3f'ANITATIOPERMl.
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<br /> Owner �.
<br /> SEPTIC TANK CESSPOOL` iLEACHIN IELD: $EEPAGE PIT ` ❑ PACKAGE PLANTy+ n '+
<br /> PERMANENT ©'TEMPORARY a NEW ,REOAIFt .r:.❑ OTHER
<br /> ra rni H Y
<br /> 5, O�CHEMIC}ALaTgILrETS
<br /> Type'Constuot '' r ! ' D1sposal Sita
<br /> { al`Unit'sl 'r Equipment Storage/Cieariing Location(s):
<br /> B. ❑ PACKAGE TRE TMENT.PLANT_-For July 1 '-June 30, 19 " ' ` rl
<br /> Operator Name : Where Certified _
<br /> a:i I 7 m kH s c s
<br /> Plant Location ,
<br /> PlentCapabity. , wr` T No;Units Served
<br /> 7 ❑.LAUNDRY i For Julyil June 30 19'
<br /> SiZE� }❑�Less,Than.1,00b 5q.:Ft ❑;,More Than 1,000 Sq Ft
<br /> ❑ dFiY CLEANINGChemi
<br /> is USediAmountlMo r
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<br /> I �)�iT^ a +y������.•f� -.., n (��LJ°Ac a w s'�„"'�S� � r?'
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<br /> I=hereby certlly that I have prepared,this application and that lhe.work'wili�be done in.accordance with San Uoaquin'Cdl1n
<br /> ordmanCesstate law's;a d rule nd re ulai' s the San Joaquin Local alth plstnct "r ' llvw �
<br /> APPLI +M}?t�Prt, ,A ty C 4! } 1 N i tk
<br /> CANT S SIGNATURE-X
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<br /> �;� !' Y FL�f `' D�11/i..i.�l . '�46 i-�h'� P ,,. A " �s.,' • � A,
<br /> AW;o ars f FOR DEPARTMENT,USE ONLY..:,
<br /> �i;,PFee�lt t}Ue
<br /> ANNUALLY _❑ PER UNIT ❑'PER SITE. ❑ EACH ,❑ Janua y,1.8 Recelvetl By lansiary 31 ❑JuIY 1 8 Rt7ceiw y.Ju7y'3,
<br /> '` rr { dILLINC x REMITTANCE
<br /> $.r '� EMIT ir"
<br /> EXPLANATION AMOUNY OUEY ,y CHECKEb
<br /> PATE ?;{ DATE FEmtITTEO '�
<br /> .._.a.7'��`.--: i� AMOUNT _
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<br /> LESS j40I PJ1,1, Jt s
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<br /> 4 -PENALTY .,
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<br /> ' 'fl' ci APPLICANT RETURN ALLrCOPIES TO -ENVIRONMENTAL HEALTI{P£RMIT1$ERVIC£3 i �` -7401 E HASELTON AVF.:PO ae[1009�Tr"tTOCRTON CA717[tt
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