Laserfiche WebLink
4 Application Will�esaed When Properly Completed.Be Sure To Sign The Ication. <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 herebymade to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br /> y Business Name(DBA) Stockon Scavenger Assoc. Address 1240 navy Dr. , Stockton <br /> i Owner Address <br /> a <br /> J Firm Partners,Addresses and Telephone Numbers <br /> I& 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. Q P ,vp <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> ❑ NEW SITE PERMIT 3PN l� <br /> ❑ SOLID WASTE TRANSFER STATION L klk"-� <br /> ❑ INDUSTRIAL WASTE GENERATOR �NMEN�R,CES <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) <br /> ❑ HAZARDOUS WASTE GENERATOR Q <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 this applicat'on d that to the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATUREX Title Date / <br /> ►�—� <br /> N STaG �tZ-- 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 ! 40.00 4 Units 1/5/89 $40.00 X <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS Itp V p <br /> PENALTY IVI BILLING DK-1E. <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 />