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Application Will Be PAblised When Property Complilghlicl.Be Sun To Sign TM AM&a'lon. <br /> APPLICATION FOR INSPECTION c <br /> CARBON NE SSARY AND NON- ASFEABLE,REVOCABLE,AND SUS DAL E SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Application is hereby made to carryon business under Permit in the jurisdiction areaof San Joa uin Local Health District. <br />� inessNeme(DBA) DCC�11 CS`�ECt�9E SSi1®— �` .�tS� f" � &A��ir"'ess C) �� t"�VE, ��SC�CD <br /> ' tJner <br /> Firm Partners,Addresses and Telephone Numbers <br /> Business Telephone No. Emergency Telephone No, <br /> Franchise Area Served <br /> L Applicants Name(Print) Title <br /> Please check Applicable Category(s).Fill in the Required Information,Return all 3 copies.Pt <br /> ray <br /> / <br /> SOLID WASTE DISPOSAL SITE,NO.39-AA- 91980 <br /> ❑ NEW SITE PERMIT /V ��® <br /> SA <br /> r <br /> 13 SOLID WASTE TRANSFER STATION ��'i jr <br /> ❑ INDUSTRIAL WASTE GENERATOR (} for;w <br /> 7P <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) AUFHORIZED >C,j <br /> 11 HAZARDOUS WASTE GENERATOR <br /> ❑ INFECTIOUS WASTE GENERATOR APPROVED <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE PRO'CESSED <br /> ❑ MIXED WASTE RECYCLING FACILITY DATE <br /> ❑ MANURE STORAGE SITE -- --- ----- CHECK NO. <br /> ❑ SITE EXEMPTION APPLICATION CCDM <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 /> 11 <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 this application and that to 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: C 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 $350.00 1 yr. 11/16/79 $350.00 <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 1001 E.HAZELTON AYE„P.O.BOX 2009 STOCKTON.CA 95=1 <br />