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NO CARBON NECESSARY <br />Application Will B When Propedy Completed. Be Sure To Sign The kation. <br />APPLICATION FOR INSPECTION <br />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 />yBusin ss Name (DBA) L. h2 r-4F^.c c R, i �— h{osp,7A _ tAJ ST Address B� 5 (--ow@ S+Acxr4wlc N Tp g'D <br />iOwner �-o�z- Mc"0It/4`-- N2sPI1'4L- Address CALt- Bog 300�{ ,e f-OOZ C -A. 955:z11I <br />4 <br />v Firm Partners, Addresses and Telephone Numbers <br />4 Business Telephone No. 2®q 33 `f - 3 `{ I ! Cr'Emergency Telephone No. <br />J 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 <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 <br />❑ COLLECTION TRUCK <br />❑ ROLL -OFF TRACTOR <br />❑ ROLL -OFF TRAILER <br />(No. to be used dually as Limited Waste Hauler Vehicle) <br />❑ RENDERING, VEHICLE <br />❑ MANUER VEHICLE <br />❑ FERTILIZER VEHICLE <br />❑ LIMITED WASTE HAULER VEHICLE <br />❑ LIMITED WASTE HAULER TRAILER <br />❑ 20 + YARD BINS, DUMPSTERS, Roll -off & Other Containers <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />------------- <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />I hereby certify that I have prepared this application and that to the best of my knowledge it is true and correct. <br />APPLICANT'S SIGNATURE X <br />Title <br />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 <br />EXPLANATION BILLING <br />REMITTANCE$ <br />AMOUNT DUE <br />CHECKED <br />DATE <br />DATE <br />REMITTED <br />AMOUNT <br />FEECJD <br />®® <br />O� <br />PCrrsi 130/91 <br />ru -C,$20 <br />00 <br />FEE <br />LESS <br />PRORATION <br />PLUS <br />PENAL17ES <br />WILL <br />PENALTY <br />n n „ <br />BEA ^' <br />BILLING ® <br />CCOUNTS 30 <br />OTHER <br />OTHER <br />I <br />Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered <br />