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Applicationrocessed When Properly Completed.Be Sure To Sign pplication. <br /> 4 *APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Applicati n is h by made to carry o usiness prider Permit in the jurisdictio area o San Joaquin Local Health istrlclt. <br /> y Business me(DBA) �ot /Jic- w� i)/ �Qr 5 � �CAddress - CT 93 <br /> z Owner V- ✓hvr diffess 02 /dd S — d <br /> a <br /> 2 Firm Partners,Addresses ano Telephone Numbers `CT[M� 0,5 4P <br /> c - 9 211i�/a3z� <br /> a Business Telephone No. 3 � Emergency Telephone No. <br /> Franchise Area Served � AJ 3 3!7 <br /> — 3 3 <br /> Applicants Name(Print) 40 Q:!�z' fi� d701-detCcL_ Title V• Date 6 Z <br /> Please check Applicable Category(s).Fill in the Required Information,Return all 3 copies. <br /> SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> ❑ EW SITE PERMIT <br /> ❑ S ID WASTE TRANSFER STATION <br /> ❑ IND TRIAL WASTE GENERATOR <br /> ❑ STATI ARY COMPACTOR(20 yd.or greater) �q "a " ` ± <br /> ❑ <br /> HAZARD WASTE GENERATOR <br /> '* <br /> ❑ INFECTIOUS STE GENERATOR '`� ;-� <br /> ❑ WASTE STORAG ACILITY Aii <br /> ❑ NEW SITE APPLICAT N FEE <br /> ❑ MIXED WASTE RECYCLI FACILITY <br /> ❑ MANURE STORAGE SITE <br /> ❑ pU <br /> i D;'v <br /> SITE EXEMPTION APPLICATION ENNv � � Li�10"1 <br /> VEHICLES AND CONTAINERS(Fill Supplemental Form) <br /> COMPACTOR TRUCK No.to be permitted <br /> ❑ OLLECTION TRUCK No.to be permitted <br /> ❑ R L-OFF TRACTOR No.to be permitted <br /> ❑ ROLL- FF TRAILER 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 /> ❑ MANUER 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,IDUMPSTERS,Roll-o &Other Containers No.to be permitted 1 <br /> Cha , aF .16vS'Ak-&-A aK8 164111 (K1, 4A 1.. CU-C. _, fl. S. So c� ag o9It,cl cS <br /> Lia 1 L'3 C.S J Q 1 S'�' S T .4 �4-H C <br /> I hereby certify that I have prep d thi application and that o best of my knowledge it is true and <br /> jcc rrect. <br /> APPLICANT'S SIGNATOR Title �- Date 1,,7 lal <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ 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 0• SOUS i� 2o.gC <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> ____+_ <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 1501 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />