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rt p , ��r �; F'� .:�fii r• APPLICATION „a ,�w,� r „ ; `
<br /> (For Non-Transferable"Revocable and Suspends
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<br /> ' t,y s; s +.& ENYFR(}NMENTAC HEALTH PERMIT
<br /> P a rr .s i ti{ Ye� APF<
<br /> I;va,, E a, �+ �r t arc s LIQUID NIASTE E J a F �i e �1z al d
<br /> AFplication Is herobv made to car on buCsin.aess,i�n the uriedictidnal area'of tKe,Zin J a uln Lacal'He Dlstrict;�
<br /> lousiness Name(t]BkZX',qT�Address�
<br /> wy ? a.w rat r'' ' s} ".d - p ^'rsa,.'r -`'� '✓ J
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<br /> ,1����+w�6i'. ,+nf r.,ar+•p;c��f la .b:�r �r s vii a >~ r �^^� a y
<br /> �"rFirm PartnArAddressesiand T'I
<br /> BLs mess ferl phonetNo t +f 0 rda .? �w 4e LI �a Erner9enay ji'a ephcntrN�,
<br /> sas r O Z sf'-3�3 ;r ,3* <, r F r ar 1 + E
<br /> Contractor CiCence Np.i Er v ;�._, r, '^ w
<br /> k'Ari x 4�-K;i a,f �. -
<br /> t Appllc�n�s"Name(Prin�) 'T7�.>1�L SC�� `''' Title 2Z2 :7_� Date
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<br /> ❑ PUMIPER VEHICLE PEtalb1I ?REGISTRATION(FOR EACH VEHICLES n I I k��*;, a 'rW rl' ��•4t i
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<br /> ,or:`J i y t� rDlsposel Sltea�
<br /> �s'rts {�
<br /> bescrip ORMakeJ�'r
<br /> Ser e l o. No � CAL License Rerswat No m Ea t 4
<br /> rlr� i ( e
<br /> to t Gel;'Weights_d Measures No
<br /> gi pPwhH !.-+rtne �tS r s ! i i 1 'b '. ..� ) 3'r�.t ,, '� �,„� S" laEr•/��S �eY >F e���`
<br /> u'pme !IPai�Ffng Addres6y:�
<br /> 2 ❑ Pr MPtR YARD m
<br /> FOt�Ju�l)'Act.. ;June 30 19
<br /> r.10 re�as, a
<br /> 0.`01-VehIC, S10►Bd:IP Tri Y..� Y '""
<br /> F;tlec N
<br /> arplikb,rf$r41? R4tl Et1 -I c f i '«� r W E c 5 - -
<br /> JNo,,a Cheri l To lets.5tored � y
<br /> 3 ❑ PERCOLA710NTIST4l;'i r 1 SKr
<br /> +`,#'w•ws�r rr� fids' A a C �, F 4 t (€,d.'Sb R S or 'ra. {
<br /> R.ti or R C EA Nema `
<br /> BIt:�C tl0h �A` '1"t �^�l.ky lr rr r�,s�Mesr S;r�Y.fi+tw rNl+, + Ta9t Dete/Time S
<br /> w .+-*,• r x spa}aw', RC4i�r t � r`� °°A;4�?T� �'P:
<br /> �1. 41
<br /> aAN ONA PERMIT „t T�r4� Fir `�lA
<br /> ob Add ess%t:ocat1c, r+a�v /T i
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<br /> 3' Y9s�F'eF y'1,µ •' J'. a,�fY5 R}
<br /> Owner �t I asAdtlress �ii►J,/ i, �A, dl�/;/l iY
<br /> ❑ $EPTIC'eTANk © CESSPOOL. ; �EACHING FIELD t C SEEPAGE PIT -F,❑„PACKAGE PLANT
<br /> d!K rc(�+v t� ❑ TEMPORAR l h❑1NEW 9 rr d i' Ela yW,k'�iEPAIR W t © OTHER t i s � I t
<br /> C' PERMANEIHlrT�R ! � y lw rt ?E . 9y }} a qr x°t l }
<br /> 5. ❑ CHEMICALT�01LET8FoiJul 1�June'3l),rt9 1” "` ; r r� ,a r�s + yL�
<br /> ly', h 'i PSn r 3 y.*sa laµ,} i,..}'+tr Y i e , >51 .
<br /> I a�,Lt-r L�?�v'F 7+"1�1r 5".Ax}� DIS Osal Sf16_ `3
<br /> Type Constn_.MIAn P
<br /> Ar jxls: epd, I ,' '!C$k` ° u-x" ' rA.yr i` fyEdrF f�„i S..e pk" T.i}''�'�`."'�t t,F:ic r
<br /> No:,.of• Jnitg Ec'(ulpment SlorageiCleaning LOcatlon(sy
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<br /> 8. ❑ PACKAGEMRE�A7MENT PLANT; Foin4uly,l�
<br /> lr• " laiA�>srM+ik� yy�'taR .Fa a la� x^r`t E� i wit@!e Ciertified r - •, ,d,
<br /> Operator Name Y
<br /> "wr.[p i�4 +a 6 fs -r'rr'� c a fi t ;4 t 5 .`F - Y•x"rl'
<br /> Plank Looatlonft gar �)r
<br /> 'y?cuiraF�X 1�9Mu.iy 4 Y 6 i -
<br /> € r
<br /> Plant!Cepeclly € ]t M ] a�; #� yt q F NO Units Sorted r„
<br /> 7 ©tiLAUNDRY For Jufy,t June 40 19
<br /> SIZE: ❑�LesG Than,1".000 5q'.`Fti F❑�Mare�•ffian t 0tH}Sq Ft �,� , �� ;$i „ � '
<br /> ❑lDRY:CLEANING Cherrlcals 0sed/AmOunUMoi
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<br /> � ly�g iyq��,yy it r •. p 4� 1Sr.,r i*f i } -h � r �,�g�•'l�
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<br /> a x .^_� ,,� _ 4•�4 ki -r Y�.�[�'� �Zdt + I p•
<br /> J41,hereby Cert ty,that I h 9e prepared this'apPliCat and that the work will tie done In accordance with San Joaquin County
<br /> Ordinancos state taW9 d rUles"and ulatlo the oa in Local Health District �.' + v
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<br /> �S��iN''�5
<br /> APP LfiCANTS`SIGNATURE
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<br /> �.� e , r • FORDE ONLY j w . x fSsj � y
<br /> Fef Is Due:❑'ANNUALLY ❑ PER!1NlT ❑ PER SITE Q EACH { r © January 1 6 Aecefved H JAnuary 7ti t`'❑July Y-b Recedd,P97�u{ 1
<br /> ,REMIT yw
<br /> 61LUNG.'` nEMrYTANCE - -$ g CHECKED -
<br /> .. AMOUNT OUEa,t;, s
<br /> i y�' nr4r BASE I EXPLANATION
<br /> �c " BATE --�bATE REMITYED r 1.:; NA'AM6UNT- �., FEE F.r ,i rry / }.- r
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<br /> �.ry Rece,k ed:by FN _ _ wE..
<br /> APPLICANT 142 TURN.ALL COPIES TO ENVIRONMENTAL HEALTH PEeMITfSERVICES `.Mill E HAxELTOH AVE.,R0. e>t 2604 STOCKTON CA 46261
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