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ApplicationProcessed When Properly Completed.Be Sure To Sign +.pplicatlon. 8HR I PON31 <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 hereby made to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br /> H Business Name(DBA) MY ty Of Ripon Address 311 11First, Ripon <br /> a Owner City Of Ripon Address 311 U Fir--,t St.- , Ripon <br /> 2 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 /> IPAYMENT <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- RECEIVED <br /> ❑ NEW SITE PERMIT ^ r ' ' " <br /> ❑ SOLID WASTE TRANSFER STATION ! (j�C ' "L ' <br /> i <br /> El INDUSTRIAL WASTE GENERATOR N'TY: <br /> I <br /> 11STATIONARY COMPACTOR(20 yd.or greater) } ION <br /> p �IC�iE ► �, � 1 <br /> 1:1 HAZARDOUS WASTE GENERATOR ENVJRQNMENTAI N` •L7*'(t ,y', <br /> ❑ INFECTIOUS WASTE GENERATOR a. <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 /> REG9 <br /> R COMPACTOR TRUCK No.to be permitted <br /> ❑ COLLECTION TRUCK No.to be permitted -8F-1_1 M9 <br /> ❑ ROLL-OFF TRACTOR No.to be per g,tsdIRMMENTAL HEALTH <br /> 13ROLL-OFFTRAILER No.to be per l <br /> (No. to be used dually as Limited Waste Hauler Vehicle) - - - - - - - - - - - - -BERM ITLSERVI v S <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 /> 1:120+YARD BINS,DUMPST ERS,Roll-off&Other Containers No.to be pern',tted <br /> I hereby certify that I have prepared this application a that to the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE X17J11-1Title 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 h 9 9Q Pegnit e 51011 2�' 89 $10.00 <br /> .• <br /> FEE <br /> LESS <br /> PRORATION PENALTIES WILL BE APPL ED TO PAST DUE ACCOU S 30 <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> 12 93 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 />