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.. . <br /> 4 <br /> Application a Processed 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 jurisdiction area of San Joaquin Local Health District. <br /> rBusiness Name(DBA) FUl1er'S ��SI. ryice Address 365 E. LOu`I AVe. s L '11 <br /> i Owner Fuller's Disposal Service Address F• Louise Ave. , Lathrop <br /> j Firm Partners,Addresses and Telephone mbe* <br /> Business 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 /> ❑ 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 /> ❑ 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,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,Roil-off&Other Containers 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 Title Date <br /> ;a <br /> FOR DEPARTMENT USE ONLY in <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan.1&Received By Jan.31 ❑ July 1&Received By July 31 <br /> REMrr <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT : <br /> FEE 22.50 8/5/80 Due 9/5/8 <br /> FEE <br /> lt[ <br /> LESS <br /> PRORATION t� C �y n 7 pn <br /> 3\ PPLUS ENALTYr2 V <br /> ¢11 .25 50% :,T/1{/80 Due 10/5/80 e <br /> OTHER <br /> OTHER <br /> Received by a Receipt No. F. Issuance Date Mailed DBlivered <br /> CKTON,CA 95201 <br /> APPLICANT—RETURN ALL COPIES TOi' ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STO `. <br />