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g %3 r', r, 11 a Processed When Properly Completed.Be Sure To Sig a Application. <br /> ��..� .1� s RY(C�� r`; ���� APPLICATION FOR INSPECTION <br /> NO CARBON '' ND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Gln' LOCAL SOLID WASTE <br /> F 1, !if L}i5TRlCT <br /> pp kation Is hereby made to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br /> NBusiness Narne(DBA) t l , / Address 1% <br /> Owner s Address BSS 'Vv P a---- <br /> 9 <br /> Firm Partners,Addresses an$� elephone Numbers <br /> Business Telephone No. x as —633L Emergency Telephone No. --- <br /> -+ Franchise Area Served �+ <br /> �Applicants Name(Print) Et /1 M 7�,,r/,:�_r Title C.� 7L4 TcGstr- Date -� <br /> Please check Applicable Category(s).Fill in the Required Information,Return all 3 copies. <br /> XSOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> ❑ NEW SITE PERMIT S�Q <br /> ❑ SOLID WASTE TRANSFER STATION �S <br /> ❑ INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) <br /> ❑ HAZARDOUS WASTE GENERATOR Ott, <br /> ❑ INFECTIOUS WASTE GENERATOR <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE P` <br /> ❑ MIXED WASTE RECYCLING FACILITY pQQ�\G <br /> 11 MANURE STORAGE SITE <br /> 11SITE EXEMPTION APPLICATION <br /> VEHICLES AND CONTAINERS(Fill Supplemental Fornt—C <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 pre d thip i ation and that t f my knowledge it is true and cor ect. <br /> v _.__. <br /> APPLICANT'S SIGNATU X w Title Date <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 /> 0 1V DATE DATE REMITTED AMOUNT <br /> FEE � / a— <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS PENALTIES MILL BE ADDED AFTER DUE DATE SHOWN BELOW <br /> PENALTY <br /> OTHER - O O <br /> f BASE FEE <br /> An DAYS- 2570 Gf BASE-FE5 <br /> OTHER 90 DAYS- 5%o of BASE FEE <br /> �-Ot- �I��I� ►o��� - <br /> Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />