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..,. Application WI seed When Properly Completed.Be Sure To Sign& <br /> ation. <br /> APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Application is hgr by m@ide t carry on busines u der Permit in the jurisdictio area of San J aqui L cal Health D'strict. <br /> r Business Name(DBA) Cal i fiorn1 a !haste Removal Systems Address 8012 N. C1 uft� �ve. , Lo i <br /> i Owner California !Taste Removal Systems Address 18012 N. C1 uff Ave. , Lodi <br /> 2 Firm Partners,Addresses and Telephone Numbers <br /> aBusiness Telephone No. Emergency Telephone No. <br /> Franchise Area Served <br /> � <br /> Applicants Name(Print) Title Date <br /> Please check Applicable Category(s).Fill in the Required Information,Return all 3 copies. ( �' <br /> 11SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> ❑ NEW SITE PERMITDo <br /> ❑ SOLID WASTE TRANSFER STATION SEP 2 <br /> ❑ INDUSTRIAL WASTE GENERATOR 2 1980 <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) SAN❑ HAZARDOUS WASTE GENERATOR A OA UIN L T L <br /> 1:1M INFECTIOUS WASTE GENERATOR 016 YIRI <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE <br /> ❑ MIXED WASTE RECYCLING FACILITY <br /> ❑ MANURE STORAGE SITE <br /> ❑ SITE EXEMPTION APPLICATION <br /> VEHICLES AND CONTAINERS(Fill Supplemental Form) <br /> ❑ COMPACTOR TRUCK No.to be permitted <br /> ❑ COLLECTION TRUCK No.to be permitted <br /> ROLL-OFF TRACTOR No.to be permitted 4 <br /> ❑ ROLL-OFF TRAILER No.to be permitted 3 <br /> (No. to be used dually as Limited Waste Hauler Vehicle) - - - - - - - - - - - - - <br /> 0 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 1 <br /> ❑ LIMITED WASTE HAULER TRAILER No.to be permitted 1 <br /> ❑ 20+YARD BINS,DUMPSTERS,Roll-off&Other Containers No.to be permitted <br /> 1 hereby certify that I have prepared thispli atio at t the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNAT �( 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 ,30 hr. 20 min. 8/5/80 Due 9/5/80 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY 5,00 50% 9/16/80 Due 10 5/8 $15.00 x <br /> OTHER <br /> OTHER <br /> rn 9 � a �fs3 , 3g s6=m3 E7 <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 />