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ApplicationWII Be iessed When Properly Completed.Be Sure To Sig Th& Rllcation. <br /> APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPEWZPABLE 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 /> F Business Name(DBA) Stockton Scavenger Assn, Address 1140 N. E1 Dorado, Stockton <br /> i owner Stockton Assn Address 1140 N_ E1 Dorado, Stockton <br /> Firm Partners,Addresses and Telephone Numbers <br /> C <br /> 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 /> 11 NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION AW HOR,dD --� <br /> ❑ INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) APPROVED <br /> ❑ HAZARDOUS WASTE GENERATOR <br /> ❑ INFECTIOUS WASTE GENERATOR PROSESSED <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE DATE PD. CHECK NO. <br /> ❑ MIXED WASTE RECYCLING FACILITY <br /> ❑ MANURE STORAGE SITE ACCOUNT <br /> El SITE EXEMPTION APPLICATION <br /> VEHICLES AND CONTAINERS(Fill Supplemental Form) <br /> In COMPACTOR TRUCK No.to be permitted 31 <br /> COLLECTION TRUCK No.to be permitted 7 <br /> ROLL-OFF TRACTOR No.to be permitted 11 <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 580 L) <br /> I hereby certify that I havep this application and that to the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGN E X 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 /> iniDATE DATE REMITTED AMOUNT <br /> FEE 70 min. 8/7/80 Due 9/7/8 <br /> FEE <br /> LESS <br /> PRORATION _ <br /> PLUS <br /> PENALTY $17.50 5 9/17/80 Due 10/7/8C $52.50 x <br /> OTHER <br /> OTHER <br /> 'Vd <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 />