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Appllcatlo Processed When Properly Completed.Be Su 1 AppllcNlon. <br /> APPLICATION FOR INSPECT n <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUS BL�979 SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERIIUN JOAQUIN LOCAL <br /> SOLID WASTE HEALTH DISTRICT <br /> Applicati n is h reby m@tde t carr on business unde Permit in the jurisdiction area of San Joaquin Local Health District. <br /> H Business Name(D A> fan Joaquin Coe . bept. of Pub i c �''�Orkkddress Lovelace Rd. , Manteca <br /> i Owner S. J. �o. Dept. of Public Works Address 1810 E. Hazelton, Stockton <br /> Firm Partners,Addresses and Telephone Numbers <br /> C <br /> 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 /> 11 NEW SITE PERMIT <br /> ® SOLID WASTE TRANSFER STATION <br /> ❑ INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) <br /> ❑ HAZARDOUS WASTE GENERATOR <br /> ❑ INFECTIOUS WASTE GENERATOR <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 6 <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 /> 11 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 prepared this appI' tion d that he best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE Title G Date 30 7 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY iK PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan.1&Received By Jan.31 fg July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE 30 kr- IS trra�h z4 100 _ 7 . 60 <br /> L L51&P <br /> p /� OD y <br /> FEE 8^30^8 A/75 X <br /> 0 <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER ^, Yyt ? <br /> -:?," 7116�1?6 V g y7 /'n 3 --In 11!16/79 <br /> Received by Receipt No. Permit Nos. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES T VIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />