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Application WHO rocessed When Property Completed.Be Sure To Sign 9ppllcatlon. <br /> APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Aplificatioji Is herep, made to carry on business and P rmit the jurisdiction rea of Sa oaquin Local Health District. <br /> N Business N me( BA) X200il,()/O'efAncTli',, /&&Address <br /> aOwner // J "a Address <br /> J Firm Partners,Addresses and Telephone Numbers <br /> aBusinessTelephone No. V Emergency Telephone No. <br /> Franchise Area Served -� <br /> Applicants Name.(Print) TitleDate <br /> Please check Applicable Category(s).Fill in the Required Information,Return all 3 copies. <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION ; Y M ►`` <br /> ❑ INDUSTRIAL WASTE GENERATOR R>E~CEI\/1rD <br /> ❑ STATIONARY COMPACTOR (20 yd.or greater) <br /> ❑ HAZARDOUS WASTE GENERATOR JUL 0 :) 1990 <br /> ❑ INFECTIOUS WASTE GENERATOR <br /> ❑ WASTE STORAGE FACILITY -11.,\11RONMENTAL HEA!""' <br /> ❑ NEW SITE APPLICATION FEEltr <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 prepared t a lication and that t best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE X5<_ Title �� Date4�" <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 <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 />