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Application V Processed When Properly Completed.Be Sure To SI*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 herel made t arry on business undeLlfermit in the jurisdiction area of San Joaq in L c Health District. <br /> rn Busines Name(DBA) ddress <br /> z Owner v` Q Address <br /> a <br /> J Firm Partners,Addresses and Telephone Numbers <br /> a Business Telephone No. L Emergency Telephone No. <br /> Franchise Area Served <br /> L Applicants Name(Print) Q Title s WJ Date <br /> Please check Applicable Category(s).Fill in the equired 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 /> 19--COMPACTOR TRUCK No.to be permitted C2 <br /> ❑ COLLECTION TRUCK No.to be permitted <br /> ROLL-OFF TRACTOR No.to be permitted Y <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 s appliq9tipin and that to the best of my knowledge it is true and correct. f/ <br /> APPLICANT'S SIGNATURE -- {t(/ Title b+- 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 EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEESID L 3 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Q Z) <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 />