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I Application t essed When Properly Completed.Be Sure To S n � 1►/ <br /> ��4aii ����..��� LLLSSS U <br /> 0 APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON TRANSFERABLE, REVOCABLE,AND SUSPEN E JAN 2 SOIVAI fA <br /> ENVIRONMENTAL HEALTH PERMIT tO�U <br /> SOLID WASTE SAN JOAQUIN LOCAL <br /> Application is hereby made to carry on business under Permit in the jurisdiction area of San JoaquiHlE-A&1FI4ItE T'1R4CT <br /> y Business Name(DBA) Harney Lane Landfill Address Harney Lane <br /> `Owner S. J. Co. Dept. of Public Works Address 1810 E. Hazelton Ave. , Stockton 95205 <br /> j Firm Partners,Addresses and Telephone Numbers <br /> aBusiness 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 /> Q SOLID WASTE DISPOSAL SITE,NO.39-AA- 003 <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 /> 1-1 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 's appli tion and that to est of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE Xl�' Title 4Z,,-CICDate t11 �d <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: Ex 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 $500.00 1 ,yr. 11/16/79 $500.00 X <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 637 <br /> Received by ate 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 />