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i Appilcatlon Will Bo^ocessed When Properly Completed.Be Sure To Sign The Iication. <br /> APPLICATION FOR INSPECTIO <br /> NO CARBON NECESSARY AND AN-TRANSFERABLE, REVOCABLE,AND PENDABLE 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 /> U) Business Name(DBA) Address <br /> i Q Owner Address <br /> J Firm Partners,Addresses and Telephone Numbers — <br /> aBus!ness Telephone No. Emergency Telephone No. <br /> Franchise Area Served <br /> Applicants Name(Print) Title 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 F , <br /> ❑ STATIONARY COMPACTOR (20 yd.or greater) ] <br /> ❑ HAZARDOUS WASTE GENERATOR g p <br /> C1 INFECTIOUS WASTE GENERATOR ' AR 1 U 1980 <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE SAN <br /> 010 ! t � <br /> 13 MIXED WASTE RECYCLING FACILITY s C}j`�r(*j�,- <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 /> 0 ,ROLL-OFF TRACTOR No.to be permitted <br /> Q"ROLL-OFF>TFlAILER 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 this application and that to the best of my knowledge it is the and correct.' x: <br /> ,APPLICANT'S SIGNATURE X Title Date <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE HOURLY ❑ Jan.1&Received By Jan.31 ❑ July 1&Received By July 31 <br /> REMIT " <br /> BASE EXPLANATION BIL;AG REMITTANCE $ AMOUNT DUE CHECKED <br /> 3 DATE TT DATE REMITTED y�+ AMOUNT <br /> FEE i�v $500.00 <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 />