Laserfiche WebLink
' Application Processed When Properly Completed.Be Sure To Sig Application.r <br /> APPLICATION FOR INSPECTIONS f � <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE <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 DiwiCt. <br /> O Business Name(DBA) Address I �4" <br /> i Owner Address 1146 X_ E1 11 <br /> 9 <br /> 2 Firm Partners,Addresses and Telephone Numbers <br /> 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 /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> 0 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 /> - - - - - - - - - - - -RENDERING,VEHICLE No.to be permitted <br /> ❑ MANUER VEHICLE No.to be permitted <br /> ❑ FERTILIZER VEHICLE No.to be permitted h fi <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 /> 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 ONLYAl <br /> ; <br /> Fes Is Dua:�p ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY 0 Jan.1&Received By Jan.31 ❑ July 1&Received By July 31 <br /> REMIV , <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED _ AMOUNT <br /> FEE f+ Yc+ 70 8—7—:0 °11,n <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> LJ <br /> Received by Date Receipt 4c'.`'__­ Permit Nos. Issuarce Date Mailed Delivered <br /> p APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 -- <br />