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i APp ons W11111 Se Pr OMW Whm.SoWnMed Properly CorrWSetmi fila Sure To Sign TIm Apptkation. +c i <br /> APPLICATION <br /> (For NoaFTrsnalera6ie>Rsvnu6te,and SuspermhMe} <br /> ENVIROM ME 4TAL HEALTH PERMIT SEPTAGE > <br /> 11QUM WASTE <br /> Application' engh tRa eta carry n rtesa in iltnsdictional area at the San Joaqu[n Laval Health Qist" t I <br /> @�+Business Name BA} -� Add.— <br /> Owner— <br /> ddress Owner _ Address --- <br /> Firm Partners.Addresses and Telephone Numbers U <br /> iBusiness Talephcme No. ����/C f ^, _:. Emergency Telephone No_ V <br /> j Contractor Licence No. <br /> ' LApplicants Name(Print f ^_ Title /meq Dam 7 <br /> r � s <br /> Please-';X APP1Ie111101e Category 11-rI prat F#I T ate mei}uirer#1t+lrmnatFon <br /> 1. © PUMPER VEHICLE PERMIT REGISTRATION(FOR EACH VEHICLE► <br /> For July~ SyJuile 30.19 Disposal mites <br /> rRescription:(M_akrp',Co1or1�. <br /> Serial No. + CAL.License No. CAL.Ltcznse Renewal No. f <br /> Capacity Gal.,Weights&Measures No. !! <br /> i Equipment Parking Address <br /> Z CE PUMPER YARD <br /> For July 1, June 36,ie <br /> No-of Vehicles Stored _ a <br /> No.of Chemical Toilets Stored IE ,.., <br /> 3. Cl PERCOLATION TEST <br /> R.S.or R.C.E.Name _ R.S.or RC E No. <br /> Test ion t Test Oaterrim ! • <br /> 4. li SANITATION PERMIT & - _ # <br /> Job Address/Loaat" R e fli 10 1 V I '4_- i <br /> 2rer Address 310 <br /> izt SAPTIC TANK 0 CE55PUC)L LEACHING FIELD LYS IT C1 YACXAdE PLANT � <br /> Off"ERMANENT ©TEMPORARY 11 NEW © REPAIR ©OTHER <br /> 5. ❑CHEMICAL TOURTS For July 1,-June 30,19 k JJF <br /> i Type Construction Disposal Sipa -e f J! <br /> No,of Units Equipment Storage/Cleaning Locations) 1-• ' - <br /> 6. © PACKAGE TREATMENT PLANT For July 1,-June 30,18 tf <br /> Operator Name- Where Certilied <br /> Plant Location ■ ` <br /> Plant Capacity - - No.Units Served. _• +rte <br /> T. ❑ LAUNDRY For July 1,-June 30,19 + <br /> i SIZE: ❑ Less Than 1,001)Sq.FL, C❑ More Than 1,0W Sq-Ft. <br /> Cl DRY CLEANING,Chemiraft UsIed/Amountfto. -.-- - - -- -- - <br /> 1 hereby cedify Thai 1 tme prepared this application and that Ute work Wlftbadorie„in accordance with San Joaquin County i <br /> ordinances,state lags,and rules and regtrlaiiot� the San Jaequin?Local IH ith T]' �'t a.nd i <br /> APPLICANTS SIGNATURE X a - - -- - - <br /> FOR DEPAiiTMENT USE ONLY ! <br /> Fee 1s Due:0 ANNUALLY I]PER VMT bla-ER SITE 13 EACH 0 Janvmy I A n cef'*d ar Jenuuy 31 ❑July I&P---)-d sr JUIy 31 i <br /> AEMT <br /> BASE EXPLANATION BILLING REMITTANCE S AMOUNTOVE CHECKED - <br /> DATE DATE REl11TTE6 AMOUNT <br /> 1 <br /> FEE - <br /> a <br /> LESS _ <br /> PRORATION <br /> PLQS T/V✓I 1)9•••••• _ _ ' <br /> OTHER V j <br /> OTHER <br /> R"W"dhY-61. Data no”no FenAlr TNo. <br /> A � �� �pc�.�Rdeik'd�/� <br /> . i'PIlCAMT—l�7tltBl AtL'.r'OPIIS a�Y�[QII�fAtRGtTIt v <br /> 1�trc�SNA2EL'Lf! AvSTOM ON.Cw%mt .• <br />