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Applicatlo Be Processed When Properly Completed.Be Sure To he Application. <br /> '4 <br /> APPLICATION FOR INSPECTIO <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 car on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br /> y Business Name(DBA) dstir a LandR1 1 Ci,,- Stkn Address Austin Road Stockton <br /> i Owner Address <br /> a <br /> Y Firm Partners,Addresses and Telephone Numbers <br /> It Business Telephone No. Emergency Telephone No. <br /> Franchise Area Served <br /> Applicants Name(Print) Ci tV Of St." "n 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,Roll-off&Other Containers No.to be permitted <br /> £' 1 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: IN 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 $500.00 1980-81 7-23-80 8-15-80 $500.00 X <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Recety"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 X009 STOCKTON,CA 991 <br />