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Application a Processed When Properly Completed.Be S II <br /> t A <br /> li <br /> APPLICATION FOR INSPEC <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPEh1§14112 SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE SANOVIQUIN LOCAL <br /> Application is hereby made to carry on business under Permit in the jurisdiction a ea�oqVjc1?A i t=Y9eaI9Health District. <br /> H Business Name(DBA)S-fit+C. k f',p N Zc q eA,/r, erS f}5•S 1✓ Address f/ Yrg 12A- 504��✓✓ <br /> z Owner.3r7°Dc 46,le ,$- 4S / /, ,Address //yy iY ��a0�%'�Od .S1�kiV, 7•l��Z r3:X- <br /> 0 Firm Partners,Addresses and Telephone Numbers C M/ 1 G>� MAZ ILAIW); . 111.2,E �ff/PC�L L 0111. S� fVYi y73 7/ / <br /> Business Telephone No. l`��"s�7 / Emergency Telephone No. :03-7/S//. <br /> Franchise Area Served 5'20'0 C-A-f4! . <br /> L Applicants Name(Print)�� �/✓i'ii� z--"q.'y'4-/ Titlee0IfP MRd sup-ee, Date <br /> Please check Applicable Category(s).Fill in the Require llnformatlon a um al oples. <br /> —� SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> ❑ 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 /> - - - - - - - - - - - - <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 prepared t is 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 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 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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 />