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Applkw#Iorw Wiif 90 PfC When SubmEted Propefly Cofnpleled,Sa Sure To bW ++M APIPIUMM"l-
<br /> "" APP1:tCATON
<br /> iL jFor Non-Trsnstersl:4,W*voasbie,and Susperidabidl SEPTAGE
<br /> ENVIRONMENTAL.HEALTH PERMIT
<br /> 1,141119 WHITE
<br /> Application is he made cartry b isinest in t oiiCdonal area oft San J g4in Lacsi Health i)i trio-
<br /> ABusiness hums(DBA) , -l ► _'t` "` -"Address"*'r��
<br /> Owner�_. Address
<br /> Firm Partners,Addresses and Telephone Nu tiers _ - - -----
<br /> L „ , Emergency Telephone No
<br /> < Business Telephone No, "
<br /> �Contractor LlCertce No. ''�`'.�-•,��.�-�-�"�►'!Re`�• ., _. _ � ,
<br /> < i _Title ,�; oalls
<br /> Applicants Name(Print)
<br /> Fiona,check Applicable Caney ry(14)pndAN In the RehlukW Inf mwbon•.r
<br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION(FCR EACH VEHICLE)
<br /> For July 1, _June•30,'-19_. "-` Disposal Sites -
<br /> Description(Mske/Yn,Color) _.... —-
<br /> t_ CAL.Lice+taa hto.. ~ CAL.Licwara Re aswal No. _: ,
<br /> Serial No. _— "
<br /> Capwity tial.,Weights A Measures No.
<br /> Equipme"htParking Address
<br /> _ f
<br /> 2. O PUMPER YARD ` v
<br /> For Juiy t .._ June 30,is
<br /> No of 1 ehioles Stored
<br /> No.of'themical Toilets,Stored t __
<br /> r'
<br /> 3. E3'PE:ACCLAstiO4YOT 7'
<br /> R.S.or R'-C.E.Name r -. ���..i,�. .� � R.S.or R,C.E.No.............. -
<br /> Test Location. .--- "' Test Datel f irne
<br /> A. 0 S1 M TAJION PONhT-'`
<br /> i
<br /> Job Address/Locsticn ' -
<br /> _ �,, _� „C;'�,►, t-•p'� arm...
<br /> --Owns, �� a1 (w *� Address..
<br /> 0 _S P•'CiC YANK ❑ CESSPOOL, ��'tO jniNG FIELD �EPAGE PIT d PACKAGE PLANT
<br /> CI PEFIMANENT 0 TEMPORARY iC1�NjrW ) ©tREPAiR+,'' L C+oTHER _ —A
<br /> "RLA a*h�'' )�,� �►`
<br /> 0-CHEMICAL"TOILETS For July 1,-June 30,19__.
<br /> e Construction
<br /> .. l Site
<br /> �. Disposal y----r--- N
<br /> row of.Units � —...- Equi6ment Storage/Clesning`LoC _`.��"--"--
<br /> a. CLIMACKAGE TREATMgNT PLANT For Duty t.-June 30..19..- �•
<br /> _
<br /> ♦ Where Certlfisd
<br /> operator Name _..._ ,.
<br /> Plant,Location ----- z—_
<br /> _
<br /> Plant Capacity_ ( No.Unita Served -
<br /> 7. 0 LAUNDRY For July 1,-June 30,119 __ -- -----�
<br /> SIZE: 0 Less Than 1,000 Sq, Ft:, © More Than 1,000 S+I.Ft.
<br /> C1 DRY CLEANING,Chemicaia Used/Amount(Ma.,�
<br /> I hereby certify that I red tJthis" 8 at the will be done in accordance with San Joaquin County
<br /> Ordinances,state taws tions of 2 J Heap fL?istrict, a ,
<br /> 4
<br /> APPLICANTS SIGNATURE X -- _ -
<br /> FOR OfPARTiMW USE ONLY. {
<br /> Fee Is Due:[7 ANNUALLY � C] ter+Warr �C7 :�rh[ ❑ :sacra O a,�+„dry+-&Perwived By damssL31r_1 July t e ar+�a By-July m
<br /> -- -
<br /> IT
<br /> �yilLtNri it1 N11T7ANGE s w' AMOUNT DUE JCHECKED
<br /> ti w
<br /> ftA$Ekh+i ANATiCRt DA7 DATE iREMrt TED AM23LlNr
<br /> " ........ mer. � ell
<br /> FEE. 4 �.-
<br /> LESS
<br /> pfioptATIONnus
<br /> _
<br /> " PEtWtiTY 1 a
<br /> OTHER i • . "". f
<br /> l
<br /> r
<br /> ,.. w,r •..� rr..w.y„� -.. ..y.•ir,:..-1...rYY ....� • "ve.- ^r �""__`L_.�.+� � - __' .
<br /> t by nstg Receipt No. t�@rmit No
<br /> ivud aaas++ms e
<br /> r- Lasatat•-neTUlW ALL COMS Ta etayatarsuiEhnrAl h�ea t*+h rr avvaEs y 1601 a tu►zitLroM Avg.,*.C.h cr es�o+
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