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Application's Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> - (For Non-Transferable, Revocable, and Suspendable) $EPTAGE ' <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> s Applicatign Is hereby ma a tfp qar on b sin m theµin dictionaI area of the S oa uin,LrI He th Ist�ncct <br /> i ( ) L. � E Address `•^ �i- f-� jT <br /> I g Business Name DBA �p �J Fes-- <br /> . ` Owner t-l` w CRL7 7 z�--� . Address . . _ . <br /> 3_Firm Partners,Addresses acofd elhone Numb rs <br /> aBusiness Telephone No. -^�._.,. .Emergency Telephone No. - <br /> .j Contractor Licence-No: <br /> L Applicants Name(Pr ni t) L E E^Y �1-- IL. Titter <br /> Please check Applicable Category (1-7) and FII' in the Required Information - <br /> 1. 0 PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1, June 30, 19- i -- Disposal Sites- -- - <br /> Description(Make/Yr., Color) - .. ... ._ -;. <br /> Serial No. V CAL.License No. -"'L- CAL`. License Renewal No. <br /> 'Capacity..• Gel„Weights'&'Measures-No:•" <br /> Equipment Parking Address _ -_.� �-_ �• <br /> 2. ❑ PUMPER YARD <br /> r 'iFbi July 1, JOne'30,-19- <br /> No.of Vehicles StoredI ` r f�I* <br /> No.of Chemical Toilets Stored - r <br /> 3. ❑ PERCOLATION TEST ��' -" <br /> fi.S.or R.C.E.Name R.S.or R.C.E.No. _ <br /> ' Test Date/Time <br /> Fest Location <br /> 4. ❑ SANITATION PERMIT g. <br /> I Addresp7Location n �� ' .' ♦+ t <br /> w�' <br /> AAddress - Y­ <br /> .Owner c <br /> SEPTIC TANK ❑ CESSPObL ❑ LEACHING FIELD ❑ SEEPAGE PIT ❑ PACKAGE PLANT = _ <br /> ❑ PERMANENT ❑ TEMP0 ARY ZNEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS Foruly 1,-June 30, 19 <br /> Disposal Site �• <br /> ' <br /> Type Construction � <br /> I No. of Units !,- a Equipment Storage/Cleaning Location(s) r-I-- <br /> 6. ❑ PACKAGE TREAITMENT PLANT For July 1, -June 30, 19 .Q `; I.i % t <br /> Operator Name L &- --•�-- here Certified r-� ' <br /> _Plant Location <br /> Plant Capacity ' No. Units Ste•-rived.• t ' t , <br /> 7. O LAUNDRY For'July 1,-IJ1�ne 30, 19 _- +�-�5-{:. ��•`��.t. ' '„3"`? x r7 T <br /> . . SIZE:4 '❑'Less than 1,000 Sq: Ftt.,_ ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. <br /> 3 1 hereby certify that Y prepared this application and at the work will be dbne in accordance with Sen Joaquin County <br /> I ordinances, ste -la e l an re ulet ns th oa in Local Health District. I I <br /> i �i� <br /> 'APPLICANTS SIGNATURE JCV` -- ._.. V 1 <br /> k - , <br /> j - - tltltl FOR DEPARTMENT USE ONLY <br /> Fee IS Due: 0 ANNUALLY III 0 PER UNIT. 0 PER SITE 0 EACH ❑ January 1 &Received By January 31 ❑ July 1 8 Received By July 31 ; <br /> REMIT <br /> 1 <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED' 1 <br /> I T DATE ATE REMITTED AMOUNT <br /> 1 FEE _ <br /> , - <br /> I <br /> PRIOR ION •y r t. I <br /> i PLUS ! <br /> ( PENALTY ' <br /> OTHER <br /> ta• <br /> I OTHER <br /> Received by Date+ Receipt No^ v 1 e Permit NO. ! --Issuance Date ailed .-.. Delivered, <br /> CA 952111 <br /> APPLICANT—RETURN All COPIES TO: ENVIRONMENTAL HEALTH PERMm/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKYON, — <br />