Laserfiche WebLink
Application rocessed When Properly Completed.Be Sure To Sigpplicatlon. <br /> APPLICATION FOR INSPECTION <br /> a NO CARBON NECESSARY AND NON-TRANSFERABLE,REVOCABLE,AND SLISPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Application is h re by made to carry o lousiness under Permit in the jurisdictio area of-San Joaquin Local Health District. <br /> F Business me(DBA) �(t I /)icy- 1,01-1-5k- i71��JCz-� S,-bM's��Address_ C�. �c?It oft/�(�CI�` I e"1 . C-4 z73 'r�SLS f <br /> a Owner 1 (/- ✓1lv! "�t� / tsLl/A('c P_ Fe s_ -1��5'> e..3c? v2 /00 c�C' c S2 - cl <br /> j Firm Partners,Addresses and Telephone Numbers �i'»� <br /> Business Telephone No. 369" _7,� _ Emergency Telephone <br /> Franchise Area Served--�a}}}�► � �G./A-) C �, / =i _)Jk`,o Ai �C r 3 <br /> L Applicants Name(Print) to/2a',� 1 IyOi dace_ Title. V. <br /> Please check Applicable Category(s).Fill In the Required Informati— ®^`•-- -"" <br /> Sc '4� �� <br /> 11 IN[ <br /> ST, <br /> 11 INF <br /> $ <br /> ❑ WA: 11�� GHd �uSt ✓�Q 55 I � � <br /> ❑ NEV C `'`�C ®� ttll•.1^.Ir ,)..J <br /> ❑ MIXI J (-1r-4 <br /> MAN <br /> ❑ SITE <br /> VEHR `r7 t��t qt \ <br /> COM tl ��� f� 1 � w <br /> ❑ OLL <br /> ❑ R vu. ro oe permitted <br /> ❑ ROLL AnR�._...... <br /> ��r, No.to be permitted <br /> (No. be used dually as Limited Waste Hauler Vehicle) - - - - - - - - - - - - - <br /> RENDERING, <br /> - - - - - - - - - - - - <br /> ❑ RENDERING, HICLE No.to be permitted <br /> ❑ MANLIER VEHICL No.to be permitted <br /> ❑ FERTILIZER VEHICLE No.to be permitted <br /> ❑ LIMITED WASTE HAULER ICLE No.to be permitted <br /> ❑ LIMITED WASTE HAULER TRAIL No.to be permitted <br /> ❑ 20+YARD BINS,PUMPSTERS,Roll-o &Other Containers No.to be permitted \ <br /> C�C.`4/gC�'+t7� �j S t A—&-A G '8 16 1�)fit^ PLA x'^C.4 '•.�y�C a K. . M. ® . Cj. J b t 1 Gl '-`�Q'�j ✓� 4 1 C) C �j <br /> �, L,)C. S 4 J Q 7 " i-�C r.JT <br /> I hereby certify that I have prep d thi application an tho /e best of my knowledge it is true and c rrect. ` s <br /> APPLICANT'S SIGNATUR Title _ �� __ Date �' Z! / ? <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan.1&Received By Jan.31 ❑ July t&Received By July 31 <br /> ------------- --- ----- —_.__--- -- <br /> REMIT <br /> BASE EXPLANATION Bit-LING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FFF ---i4 Gz©•O� -- <br /> 0� <br /> FFF <br /> LFSS <br /> PRORATION <br /> PLUS--- - — — <br /> rr.lci ry <br /> ,rr,FR <br /> �,?tlFn <br /> Received by Date Receipt No Petnol 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 />