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ApplicationProcessed When Properly Completed.Be Sure To Sly Application. <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 urisdiction area of San Joaquin Local Health District. <br /> H Business Name(DBA)7?,&V?J' Fig-tV t L Y pV QyN/NGtff�Lfft �� �ess 9y`� /V. C>L7V?p(' 5r <br /> z Owner Address <br /> C <br /> j Firm Partners,Addresses and Telephone Numbers <br /> Business Telephone No. <br /> A16 4; 335�3'� Emergency Telephone No. X77 6.212— <br /> on' <br /> Franchise Area Served _ <br /> Applicants Name(Print) %3~55C61 ZUzy/NO Title ��G �L� 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 /> ❑ NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION <br /> ❑ INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR (20 yd.or greater) <br /> ❑ HAZARDOUS WASTE GENERATOR <br /> C 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 prep red is a lication and a t e best of my knowledge <br /> it is true and correct. <br /> APPLICANT'S SIGNATURE Title/ e Un4 ge' ate <br /> FOR DEPARTMENT USE ONLY <br /> ee ISDue: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH 11 HOURLY 11 1,,,1&Received By an.31 11 1,1,1&Received By July 31 <br /> REMIT <br /> / <br /> L BA E EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED 7 DATE DATE REMITTED AMOUNT <br /> FEE <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 />