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p Ca Processed When Properly Completed. Be Sure To SI AppUcatlon. <br />APPLICATION FOR INSPECTION <br />NO CARB Es A Ok_-114ANSFERABLE, REVOCABLE, AND SUSPENDABLE SOLID WASTE <br />tYR 2 4 I5� <br />ENVIRONMENTAL HEALTH PERMIT <br />SAN JOAQU I N l_n(' n L SOLID WASTE <br />AppiifgEAL"elDI6*RJ f,Cprry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br />y Business Name (DBA) Address_ 321 W. Turner Rd. , Lodi <br />i Owner Address <br />s <br />2 Firm Partners, Addresses and Telephone Numbers <br />aBusiness Telephone No. Emergency Telephone No. <br />Franchise Area Served <br />L Applicants Name (Print) Title Date <br />Please check Applicable Category(s). Fill in the Required Information, Return all 3 copies. <br />Im <br />SOLID WASTE DISPOSAL SITE, NO. 39 -AA - <br />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 <br />COLLECTION TRUCK <br />ROLL -OFF TRACTOR <br />ROLL -OFF TRAILER <br />(No. to be used dually as Limited Waste Hauler Vehicle) <br />RENDERING, VEHICLE <br />MANUER VEHICLE <br />FERTILIZER VEHICLE <br />LIMITED WASTE HAULER VEHICLE <br />LIMITED WASTE HAULER TRAILER <br />20 + YARD BINS, DUMPSTERS, Roll -off & Other Containers <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />------------- <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />I hereby certify that I have prepayplication and thatw1r—eb-eTMf my knowledge it-,' true and correct. <br />APPLICANT'S SIGNATURE itle !i'7i I`Y�[ GY Date •4— a—o <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 />BASE <br />- EXPLANATION <br />BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered <br />•Col Ir ANT_OCTI ICY At 1 rnolcc Tn. CWVIOn YOCUTw1 uCwl 7161 oeou-COVIrCe .em a uw90 Tnu wve n n nnv nnne ernrvrnu r♦ eeM. <br />