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* t Applicatlor Be Processed When Properly Completed.Be Sure To S e Application. <br /> ° APPLICATION FOR INSPECTIO <br /> I NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLI"AISTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> 9 <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 /> y BusinessName(DBA) 7tin Landfill Ci Of S :•;Address Austin Road. Stockton � <br /> i Owner Address <br /> a <br /> S2 Firm Partners,Addresses and Telephone Numbers <br /> COL' Business Telephone No. Emergency Telephone No. <br /> J Franchise Area Served <br /> �Applicants Name(Print) 1i til of Stockton ton Title Date A. <br /> Please check Applicable Category(s).Fill in the Required Information,Return all 3 copies. <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> 1:1 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 /> 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 <br /> S500.00 PI0-81 7-23-80 Ne 8-15-8 <br /> FEE ' <br /> 1 250.00 50% 8-19-80 )ue 9-15-80 $750.00 X <br /> -PLUS <br /> = PENALTY <br /> OTHER <br /> OTHER <br /> i F, Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered <br /> -- APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1801 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 -- - <br />