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Application Processed When Properly Completed.Be Sure Toowpplicatlon. <br /> APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Applicatio g hereby made o carry on busin ss nderP r it in the' isdictio r o S Jpaq n Loc He lth District. <br /> �i sta Ray eon escen f�'osp� a`� Iff y�'vi a `fir. , �oc�i <br /> vJ Business me(DBA) Address <br /> i Owner 1BcA Address u 7-0 S U 101 13_2� Jur 'A t . C'n <br /> a <br /> J Firm Partners,Addresses and Telephone Numbers <br /> 00* Business Telephone No. —G- Emergency Telephone No. <br /> x Franchise Area Served <br /> �Applicants Name(Print) 1�—s �� —t`'� n Title r Date fU2 <br /> Please check Applicable Category(s).Fill in the Required Information, <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> E3 NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION <br /> ❑ INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) <br /> ❑ HAZARDOUS WASTE GENERATOR <br /> INFECTIOUS WASTE GENERATOR <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE <br /> ❑ MIXED WASTE RECYCLING FACILITY <br /> ❑ MANURE STORAGE SITE <br /> ❑ SITE EXEMPTION APPLICATION <br /> VEHICLES AND CONTAINERS(Fill Supplemental Form) <br /> ❑ COMPACTOR TRUCK No.to be permitted <br /> ❑ COLLECTION TRUCK No.to be permitted <br /> ❑ ROLL-OFF TRACTOR No.to be permitted <br /> ❑ ROLL-OFF TRAILER No.to be permitted <br /> (No. to be used dually as Limited Waste Hauler Vehicle) - - - - - - - - - - - - - <br /> RENDERING, <br /> - - - - - - - - - - - - <br /> RENDERING,VEHICLE No.to be permitted <br /> ❑ MANUER VEHICLE No.to be permitted <br /> ❑ FERTILIZER VEHICLE No.to be permitted <br /> ❑ LIMITED WASTE HAULER VEHICLE No.to be permitted <br /> ❑ LIMITED WASTE HAULER TRAILER No.to be permitted <br /> ❑ 20+YARD BINS, DUMPSTERS,Roll-off&Other Containers No.to be permitted j <br /> I hereby certify that I have prepared s a lication and that tp the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan.1&Received By Jan.31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE $30.00 6/17/85 Die 7/17/85 $30.00 X <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS /t Ji' <br /> PENALTY (,�►� <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />