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Application Wi' Processed When Properly Completed.Be Sure To Sign 10 <br /> ppllcation. <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 /> r Business Name(DBA) Tracy Delta Disposal Service Address 99 11, 6th St. , Tr3r�y <br /> Owner Tracy Delta Disposal Service Address 105E 120, Tracy <br /> J Firm Partners,Addresses and Telephone Nu bers <br /> aBusiness Telephone No.—meq rC z 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 PAYMENT <br /> ❑ SOLID WASTE TRANSFER STATION RECEIVEDQ <br /> 11INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) UCC 19 89 <br /> ❑ HAZARDOUS WASTE GENERATOR <br /> ❑ INFECTIOUS WASTE GENERATOR SAN JQFiUi�\Sc�'^+ "^^ <br /> ❑ WASTE STORAGE FACILITY PUBLIC T ENVIRONMENTAL <br /> L T%�-... . <br /> 13 NEW SITE APPLICATION FEE <br /> ENVIRONMENi ;= �ti:a1CN <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 /> 9 COLLECTION TRUCK No.to be permitted <br /> la 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 /> 11 RENDERING,VEHICLE No.to be permitted <br /> ❑ MANUER VEHICLE No:;0 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 ap kationthat to the best of my knowledge it is tryAand correct. <br /> n l <br /> APPLICANT'S SIGNATURE X Title. Date f_ <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 /> 7 BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 30.00 3 additional 11/20/39 $30.00 <br /> FEE Vehicles - <br /> LESS <br /> PRORATION WILL BE APPLIED TO PAIST DUE ACCOUNTS 30 <br /> PLUS DAYS FROM BILUNG DATE. <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 96201 <br />