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Applicationrocessed When Properly Completed.Be Sure To Sig pplication. <br /> Or APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Applicatio is heretw made to carry on bu ' ess under P rmit in the ju I6on area f Sa Joaquin Local Health District.� 095: <br /> y Busine s Name(D ) d 5 d rd es � X�[�Y/� . �` Sr — <br /> i Owner e C - �� V o beo awbel/ xock. ��r!/ 9s a/ <br /> a <br /> 52 Firm Partners,Addresses d T lep one Numbers <br /> ILL Business Telephone No. Emergency Telephone No. � F. l-6zk 33 �Z <br /> Franchise Area Served -JY--Fl <br /> L Applicants Name(Print) U 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 /> ❑,,SOLID STE TRANSFER STATION <br /> ❑ INDUSTRIA ASTE GENERATOR <br /> ❑ STATIONARY C PACTOR(20 yd.or greater) <br /> n���R�{ <br /> ❑ HAZARDOUS WAS GENERATOR ryy ' <br /> ❑ INFECTIOUS WASTEG RATOR <br /> ❑ WASTE STORAGE FACILITY JV N ni <br /> ❑ NEW SITE APPLICATION FEE Sd�l�3 1,� P <br /> ❑ MIXED WASTE RECYCLING FACILITY P(Ira �� °jjV co'_Pj�)r�. <br /> ❑ MANURE STORAGE SITE ENV,I�r��;,`I�t;�� `�t Itj fV �rJ <br /> ❑ SITE EXEMPTION APPLICATION <br /> VHICLES AND CONTAINERS(Fill Supplemental Form) <br /> ❑ CO ACTOR TRUCK No.to be permitted <br /> ❑ COLLE ON 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 1 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, DUMP TERS,Roll-off&Other Containers No.to be permitted <br /> CL�,,.�� 4M ��s�Kess �.,0 -'II��1 ►�-4�es : C"-ne- 5�.,,��y c;1-..� so�'�a W4 Le ���I��s <br /> C 4I W 4, w�c J a l'I'l 6 S� �H L.. <br /> I hereby certify that I have prepar thi app licati n and hat the best of my knowledge it is true an rrect. <br /> APPLICANT'S SIGNATURE Title Date -/ <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 'Z C) CJ -- <br /> FEE <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 />