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Application*Processed When Properly Completed.Be Sure To Sig Wpplication. <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 ade to carry on bu 'Hess under Permit in the jurisdiction area of San Joaquin Local <br /> Health District. <br /> wBusiness Name(DBA) ZM=f Add ss <br /> z 0wner40a9tG.484M.f=e!Wa�r_4 7kr-1A 9/& re. Address 0 IN <br /> Y Firm Partners,Addresses an ele hone Numbers oO 4ku-- '" <br /> COL' Business Telephone No. �" ����J— Emergency Telephone No. � t� .1211-14 Z2_ <br /> J Franchise Area Served <br /> L Applicants Name(Print) r-+��-fJ Title N `r - Date J <br /> Please check Applicable Category(s).Fill In the Required Information,Return all 3 copies. <br /> jjwq. <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- v' , <br /> ❑ NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION /�- <br /> ❑ INDUSTRIAL WASTE GENERATOR �,�_� G 1 ,�+4t\ <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) <br /> ® HAZARDOUS WASTE GENERATOR (�u <br /> ® INFECTIOUS WASTE GENERATOR <br /> ❑ WASTE STORAGE FACILITY jj , . <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 Is ap ication and that to the best of my knowledge it is true/and correct. <br /> APPLICANT'S SIGNATURE X TitleDate <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 OO <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 />