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1y Applicatioe Be Processed When Properly Completed.Be Sure To S e 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 hereby made to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br /> y Business Name(DBA) California Waste Removal Systems Address 18012 N Cl uff Ave. , Lodi <br /> Owner Rudolph Vaccarezza Address P.O. Box 226, Lodi <br /> Y Firm Partners,Addresses and Telephone Numbers .e <br /> C& Business Telephone No. Emergency Telephone No. <br /> � Franchise Area Served \ <br /> L Applicants Name(Print) Title Date •` <br /> Please check Applicable Cate o <br /> pp g ry(s).Fill in the Required Information,Return all 3 copies. <br /> A <br /> 11SOLIDWASTE DISPOSAL SITE,NO.39-AA- <br /> ❑ NEW SITE PERMIT / <br /> f <br /> SOLID WASTE TRANSFER STATION <br /> ❑ INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) <br /> 1:1 HAZARDOUS WASTE GENERATOR �0+lN� �Qbb-b� <br /> 1-1INFECTIOUSWASTE GENERATOR G"I ONS <br /> RAGE FACILITY <br /> 11 NEW S11 ITE APPLICATION IFEE <br /> QV�S�(� <br /> ❑ MIXED WASTE RECYCLING FACILITY r� <br /> ❑ MANURE STORAGE SITE <br /> ❑ SITE EXEMPTION APPLICATION ` <br /> VEHICLES AND CONTAINERS(Fill Supplemental Form) <br /> ❑ COMPACTOR TRUCK No.to be permitted <br /> ❑ :OLLECTION TRUCK No.to be permitted <br /> ❑ ROLL-OFF TRACTOR No.to be permitted <br /> L. 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 /> u 20+YARD BINS,DUMPSTERS,Roll-off&Other Containers No.to be permitted <br /> I hereby certify that I have prepared this pplicati nd hat to the st of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE X Title 1 [ ig,[ Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: IR 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 81/82 7-1-81 Due. 7-31-81 $350.00 X <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> or E .QFTE� ®UE <br /> OTHER _ ATE SHOWN BELOW <br /> , <br /> OTHER C ® PAYS 21 c' RA-SE FEE <br /> IT, FIE <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 /> 7 <br />