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Application W 0 rocessed When Property Completed.Be Sure To Sign ppllcation. <br /> APPLICATION INSPECTION <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 carry on busil ss under Permit in the jur' I on area[ f San Joaquin Local Health Distro t. <br /> r Business Name�(D ) A 7/i i �/ f'2`Lc/ !1 >t /� d res_ /40 At$X���,t/��C� L 1 t — <br /> a Owner t1�C VC4CCC r !C_..,�'Ak r &C t Z` <br /> J Firm Partners,Addresses�nd-/T lee one Numbers c� c' s <br /> aBusiness Telephone No. ► s'� ^l_.� �7 —_ Emergency Telephone No. 'V -� Z&� Z"�/ ��� L <br /> ll j i c <br /> J Franchise Area Served <br /> Applicants Name(Print) 0/ 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 /> ❑ N SITE PERMIT <br /> ❑ SOLI <br /> ., D STE TRANSFER STATION <br /> ❑ INDUSTRIA ASTE GENERATOR <br /> ❑ STATIONARY C PACTOR (20 yd.or greater) r� <br /> ❑ HAZARDOUS WAS GENERATOR <br /> ❑ INFECTIOUS WASTE G RATOR <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE <br /> ❑ MIXED WASTE RECYCLING FACILITY-",, <br /> ❑ MANURE STORAGE SITE <br /> ❑ SITE EXEMPTION APPLICATION <br /> V HICLES AND CONTAINERS(Fill Supplemental Form) <br /> ❑ CO ACTOR TRUCK No.to be permitted <br /> ❑ COLLEMION TRUCK No.to be permitted <br /> ❑ ROLL-OFF CTOR No.to be permitted <br /> ❑ ROLL-OFF TRAIL No.to be permitted _ <br /> (No. to be used / 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 /> 1:120+YARD BINS,DUMP�TERS,Roll-off&Other Containers No.to be permitted <br /> C c o� 6"s; ess 4,.,e) l��11 + VS4,s, <br /> t-4—esC" e Sc, ,, �c C; spl�d was �e �r�Ic�S <br /> CA1 Wa54,--j22wb %/G ' <br /> I hereby certify that I have prepay th applicati nand hat t�/the best of my knowledge it is true an rrect. <br /> APPLICANT'S SIGNATURE l cLG Title s Date <br /> i' <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan i&Received By Jan.31 ❑ July 1&Received By July 31 <br /> -- --- <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> 7 DATE DATE REMITTED AMOUNT ` <br /> ITf 20.x® <br /> zo o <br /> CEE <br /> LCSS <br /> VIII)RATION <br /> PLUS <br /> rr1A1 TY <br /> oTHrn <br /> nTHrn <br /> nararveri by Data 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 />