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,A <br /> 11�plpiication a Processed When Properly Completed.Be Sure To Si a Application. <br /> 3_5 ,J L; i J„ APPLICATION FOR INSPECTION <br /> NO CARBON NECESIIII AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> HEAkLTH <br /> ApplicatiRQn s h reby mad carrX on business urtd r Permit in the jurisdictionjof an aquin Local He Ith Di$t[ict. <br /> FBusiness Name(DBA) l,a�1 Trom a 1 1 aJ U1 S p0Sa I J1 to Address T` UOra2t, COCKLon <br /> Owner_ Cove .on rartoL^S, Inc- <br /> 9Address ockton <br /> Z Firm Partners,Addresses and Telephone Numbers P.�. 6�T0 Stockton 95206 <br /> 101 a Business 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 /> XII 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 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 j(i' p c ion and o the best of my knowledge ittis�true and correct. <br /> APPLICANT'S SIGNATURE X Title L" !—47bW 1 Date_ /©—o;61_ijF U <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 $500.00 80/81 10/1/80 Due 11/1/8 $500.00 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> inial Y6 5lka� a Asa <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 />