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Applicatl Processed When Properly Completed.Be Sure To S Application. <br /> APPLICATION FOR INSPECTIO <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Application is qereby m e tC rry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br /> UBusiness Name(DBA) Address loot • <br /> cOwner 2 Address ZS 2_�o4—►s <br /> j Firm Partners,Addresses and Telephone Numbers <br /> a Business Telephone No. Emergency Telephone No. <br /> Franchise Area Served <br /> L Applicants Name(Print) 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 /> 0 NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION I� <br /> 1:1 INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 <br /> or d. greater) <br /> Y " <br /> ❑ HAZARDOUS WASTE GENERATOR l i G _ US 1980 <br /> 11 INFECTIOUS WASTE GENERATOR FIV U <br /> ❑ WASTE STORAGE FACILITY ENVIROMEi:TAL HEALTH <br /> ❑ NEW SITE APPLICATION FEE <br /> 11 MIXED WASTE RECYCLING FACILITY F ERMIT/SERVICES <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 <br /> ❑ ROLL-OFF TRAILER No.to be permitted <br /> (No. to be used dually 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 /> ❑ 20+YARD BINS,DUMPSTERS,Roll-off&Other Containers No.to be permitted <br /> I hereby certify that I have pre are tl is applica ion nd that t best y knowledge it i t�ru/e and correct. <br /> APPLICANT'S SIGNATURE X Title Gv 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 L AMOUNT <br /> —7 <br /> FEE 30 �r !O HVl f'v1 3 <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> P1 X, `$ Ll -? M 3 3/ <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 />