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Applicatio*a Processed When Properly Completed.Be Sure To SI*a <br /> 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 /> H Business Name(DBA) San •1na ri n ('minty Housing A t hor ss 136 Chung Vlah Lane <br /> Owner Can ,Jamin HOliSingAllthnrity Address -- P.O. rSox 447. Stockton <br /> Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. 6(le, -sns If 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 /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- O�`I <br /> ❑ NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION <br /> ❑ INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) <br /> 1:1 HAZARDOUS WASTE GENERATOR <br /> ❑ INFECTIOUS WASTE GENERATOR <br /> FACILITY1-1 WASTE STORAGE <br /> 1:1 NEW SITE APPLICATION FEE1:1 MIXED WASTE <br /> 1:1 MANURE STORAGE SITE RECYCLING FACILITY <br /> ❑ SITE EXEMPTION APPLICATION <br /> VEHICLES AND CONTAINERS(Fill Supplemeftl Form) <br /> 1:1COMPACTOR TRUCK No.to be permitte �1.,L__2 Q 19 <br /> ❑ COLLECTION TRUCK No.to be permitted <br /> ❑ ROLL-OFF TRACTOR No.to be permitte {H�.00AL HEALTH DIST• <br /> 1:1ROLL-OFF TRAILER No.to be permitte NTAL HEALTH DIV. <br /> (No. to be used dually as Limited Waste Hauler Vehicle) - - - - - - - - - - - - - <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 5 <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 andthatto the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATUREV Title ���ate Z <br /> AI AP If <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 $50,00 81/82 7/9/81 Due 8/9/81 $50.00 X <br /> FEE <br /> LESS <br /> PRORATION PWALTIES WILL BE ADDED AFTER - <br /> DATE SHOWN! BELOW <br /> PEN 30 DAYS 00,0 of BASE EE <br /> PENALTY <br /> OTHER 60 DAYS-250/o o BASE EE <br /> OTHER LL <br /> -7 7 VZ <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 />