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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br />APPLICATION <br />(For Non -Transferable, Revocable, and Suspendable) <br />ENVIRONMENTAL HEALTH PERMIT SEPT�,GE <br />LIQUID WASTE <br />Application is here y ad of ry on business in the jurisdictional area of the San Joaquin 1_ Heaf th District <br />F Business Name (DSA) J�t2� l T Address .lam_ ,_— M° <br />aQwner..__. iii/A�.- ►� Address ..le'7 <br />Firm Partners, Addresses and Telephone Numbers <br />aBusiness Telephone No. __ 5^ ----------- Emergency Telephone No. <br />Contractor Licence No.'�� <br />LApplicants Name (Print) ��rs — G' ,el � Title eP�Ao"Sf "_dam. Date <br />Please check Applicable Category (1-7) and Fill in the Required Information <br />1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) <br />For July 1, June 30, 19 �_._...__.. Disposal Sites <br />Description (Make/Yr., Color) <br />Serial No. _ CAL. License No. __._... CAL. License Renewal No._ ......... _.... _............ _.................. <br />ti <br />Capacity Gal., Weights & Measures No. __. _..... ....... ...__ <br />Equipment Parking Address.-- '�!• q !, I, <br />2. 0 -PUMPER YARD <br />For Jultl June•30; 19 <br />No. o Icles tore <br />No. of Chemical Toilets Stored <br />3. ❑ P TEST <br />R.S. o R Name R.S. or R.C.E. No. <br />Test L c tion�� Test Date/Time <br />SANITATION PERMIT <br />Jot��GldrPsS/LocatiQr <br />OwnerllFC <br />-�f+ /J Address „/l�7 �ie4..ers e2r�-�j-cc _ <br />5, L-1 <br />11C <br />N0.rof U <br />61 j❑j P <br />O�i�jrat0 <br />Plant Lc <br />Plaf <br />7 <br />SIZI <br />Clr <br />APF <br />0-6ESSPL30L LE HING ELELD :KLSEEPAGLPLT <br />4NENT ❑ TEMPORARY NEW REPAIR <br />EMICAL TOILETS For July 1, - June 30, 19 <br />structlonj� Disposal Site <br />its i t Equipment Storage/Cleaning Locations) . <br />CCKKA, G-k)�i ATMENT PLANT For July 1, - JunT, 19 <br />in <br />No I1nitR SP.rw-d <br />IJ PACKAGE PLANT <br />❑ OTHER <br />Where Certified <br />31 DRY July 1. - June 30, 19 <br />AFor <br />- "Less Titan 1,000 Sq. Ft., C3 More Than 1,00 iSq. Ft. <br />RY LEAN CNIG-.Chemicals Used/AmountlMo. 1 <br />I hereby certify that I have prepared this application a d that the work will be done in accordance with San Joaquin County <br />an; <br />ordinances, state laws, and rules and regulatio r t an'Joaquin Local Health District. <br />r <br />LIC ;,NT'S SIGNATURE ` <br />FOR DEPArRTMENT USt� L <br />Fee IS Due: ANNUALLY ❑ PER UNIT WIPER SITE Jr"❑ EACH ❑ u y 1 & Received By January 31 ❑ JUIy I & Received By July 31 <br />13Y <br />a I1 G <br />'TANCE <br />$ <br />REMIT <br />BASE <br />EXPLANATION 1 <br />D E <br />ATE <br />REMITTED <br />AMOUNT DUE <br />CHECKED <br />AMOUNT <br />FEE <br />.. <br />........................... <br />LESS <br />PRORATION <br />........._.........._ ..................- PLUS �' l <br />PENALTY... .�.,. .,..�,-..a.+. <br />PENALTY - <br />... <br />+.-.�....-.�...�..� ,........+....—.-..�.,.., <br />OTHER <br />OTHER <br />i <br />�Y"\ <br />+... �`{ �! <br />�,,J�y+C^j ►•,ti <br />-- -- _ .._ . <br />OTHER <br />d lS �1 <br />Receive_ ate Receipt No Permit Nu. 88u nce Date Mal Od .... Deliv led <br />,...... 10CH If:ANT......RFTIIRN ALL rnOIER Tn^ FNVIRONMFNTAI 14FAI TN pFRMITlRERVICEC 14%nt IF. MA2FLTON AVE_ b n Rn. IXWQ RTM KTAN A AS].7. <br />