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ApplicationProcessed When Properly Completed.Be Sure To Sty Application. <br /> APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Application is herb made to carry on busines and r Permit in the jurisdiction area of San Joaquin Local tiealth Dis3rl t. <br /> r �'e. A ress a �o,•, 9csad<s' <br /> H Business Na (Dl A) <br /> i Owner c 40ddress e <br /> u Firm Partners,Addresses and Telephone Numbers <br /> Co.- Business Telephone No. - - t Emergency Telephone No. -2,02 y- y� 7 <br /> -+ Franchise Area Served <br /> �Applicants Name(Print) Title 4 t- Date <br /> Please check Applicable Category(s).Fill in le Required Information,Return all 3 copies. M <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> 0 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 GENERATORJ�� <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 <br /> I hereby certify that I have prepar appli •tion and that to the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE X Title "I AMI v�� Date -7 <br /> APPLICANT'S <br /> 'f X V '- d`t7 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 104444 o,00 *- .'17 r <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 /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />