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hr, <br /> i •«�+ir APPlicatlo Be Processed When Properly Completed.Be Sure To a Application. <br /> APPLICATION FOR INSPECTION l <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLU), <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 /> HBusiness Name(DBA) Address <br /> Owner — — Address --- <br /> j Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Franchise Area Served <br /> 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) iiJ II �i <br /> ❑ HAZARDOUS WASTE GENERATOR <br /> ❑ INFECTIOUS WASTE GENERATOR �g�nU Q 198anp <br /> ` ❑ WASTE STORAGE FACILITY h1A 0 <br /> ❑ NEW SITE APPLICATION FEE <br /> ❑ MIXED WASTE RECYCLING FACILITY SAN Jop011 ' <br /> ❑ MANURE STORAGE SITE HEAINLTH DfS. <br /> ` ❑ SITE EXEMPTION APPLICATION ," <br /> CIT <br /> VEHICLES AND CONTAINERS(Fill Supplemental Form) <br /> f .. ❑ COMPACTOR TRUCK No.to be permitted g <br /> f ❑ COLLECTION TRUCK No.to be permitted * <br /> ❑ ROLL-OFF TRACTOR No.to be permitted <br /> #' <br /> ❑ ROLL-OFF TRAILER - - No.to be permitted- <br /> (No. <br /> ermitted(No. to be used dually as Limited Waste Hauler Vehicle) - - - - - - - - - - - - - <br /> RENDERING, <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 e . <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 1 have prepared this-application and that to the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE Title` Date <br /> FOR DEPARTMENT USE ONLY <br /> `Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan.1 B`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 /> 00 <br /> FEE <br /> !1 i � (' <br /> ---- <br /> s. FEE <br /> LESS <br /> PRORATION - - <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by t 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 /> 1 <br />