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APPLICATION / <br /> ^r (For Non-Transferable;Revocable,and Suspend able) SEPTAGE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> / tr: LIQUID WASTE <br /> y* w Application is hereby made to carry on business In the jurisdictional area of the San Joaquin Local Health District <br /> Tne. - Address P•o• Box 4463, Modesto, CA 95352 <br /> Business Name (DBA) TriCmintyRders, - <br /> : OwnerAndreWEmuwez',R.Vande KiP--ftAddress P•C• BOX 4463, Modesto, -CA 953M <br /> Firm Partners, Addresses and Telephone Numbers - -- <br /> Business Telephone No. _ 209 521-7443 -Emergency Telephone No. ti a <br /> f <br /> Contractor Licence No. 2857:78. President 12/10 81 I <br /> r rl 1Ln r Title v Aate , <br /> Applicants Name(Print) . - T� <br /> Please check Applicable Category (1-7) and Fill In a equired In ormation )t <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) l <br /> For July 1,_ _June 30, 19 - Disposal Sites - l <br /> Description(Make/Yr., Color) <br /> Serial No. _CAL. License No. _ CAL. License Renewal No._ <br /> Capacity Gal-7 Weights & Measures No"-' ""�"' " �" ... - � ..• <br /> _ <br /> Equipment Parking Address --- <br /> 2. ❑ PUMPER YARD _ <br /> For July 1,_- - June 30, 19 <br /> a <br /> No. of Vehicles Stored - <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST .. <br /> R.S. or R.C.E. Name. - ` R.S. or R.C.E. No <br /> Ts- - Test Date/Time <br /> HYAd', <br /> L cation <br /> ANITATION PERMIT Z r s V <br /> ,7750ast Highway #4. Stockton_ •� r� <br /> ress/Location•_-.L - C <br /> r�, �.t2ri n 4 Address—.172Q_Bast Highyiay At Stoc]tu�n, CA <br /> -Owner- S.z��Lner-S ���, ' ❑ PACKAGE PLANT <br /> NSEPTIC TANK ❑ CESSPOOLI . L.EACHING FIELD ❑ SEEPAGE PIT OTHER <br /> .1 <br /> ❑ PERMANENT- ❑ TEMPORARY k NEW kits-��• ❑ REPAIR t <br /> 5. ❑ CHEMICAL TOILETS For July 1,-"June 30, 19• -� ~ `1 <br /> Type Construction i ',F 1 y ,Disposal Site_ <br /> No. of Units' Equipment Storage/Cleaning Location(s) <br /> 6. ❑,PACKAGE TREATMENT PLANT For July 1, -June 30. 19_ <br /> Where Certified - ---+ <br /> Operator Name <br /> Plant Location — <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 - <br /> SIZE ❑ Less Than 1.000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. _ <br /> Hams owner or licso <br /> snd egent's signature cLriuics t!�a fcIIrwirg:'I certihr!hnt�n fhe per ciriance of 1`1e work for which fhls p?•mit is issued,I sha!I not employ ary person <br /> in such nlalmer as to become s�;bn..1 to wurkran's compe,-Aatinn tart's;:f C;!ifomi;j.- <br /> Contraetoi 6 hiring or sub-eontrRC•ting elgneu N certifies thi- forrowing: I certity Mat in tho perlorrrlmce of thr wurk for which this permit is issued,I shall <br /> employ persons sutimt to workman s coTuensamn laxs pt Cal:fornla <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules arA re ulati ns of h San Jo a uin DI Health Oistric <br /> APPLICANT'S SIGNATURE X <br /> r' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: C3ANNUAI LY ❑ PER UNI1 ❑ PER SITE ❑ EACH Wopo❑ Januory 1 a neceived By January 31 ❑ Juty Received 8y July 31 <br /> i REMIT <br /> BASE EXPLANATION BILI INC. T.R MITTANCE E AMOUNTDUF CHECKED <br /> DATE . DATE REMITTED AMOUNT <br /> FEE -.— <br /> LESS I i <br /> PRORATIOPLUS <br /> N � - <br /> PENALTY <br /> —��JZ4 -- ' <br /> OTHER 1 f �� tW' LO� Al - - <br /> ' <br /> w <br /> OTHER <br /> Rnrrrved b �- Uaa1 Receipt No. Permit No. Issuance Date Mailed Deliv.red <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIYiSERVICES 1601 E.HAZELTON AVE..P.O.Box 2009 ST , KTON,C 95201 -• <br />