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Application Will Be Processed When Property Completed. Be Sure To Sign The Application. APPLICATION FOR INSPECTION NO CARBON NECESSARY AND NON -TRANSFERABLE, REVOCABLE, AND SUSPENDABLE ENVIRONMENTAL HEALTH PERMIT SOLID WASTE Application is hereby made to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. ,, Business Name (DBA) -Lodi Odi MPmariz Hwspi t3LASSOC. Addresses 5_S__EaiM011 - AVB _ .Od1_ Owner14 Address J Firm Partners, Addresses and Telephone Numbers ILLa Business Telephone No. Emergency Telephone No. J Franchise Area Served L Applicants Name (Print) Title Date Please check Applicable Category(s). Fill In the Required Information, Return all 3 copies. ❑ SOLID WASTE DISPOSAL SITE, NO. 39 -AA- _ ❑ NEW SITE PERMIT ❑ SOLID WASTE TRANSFER STATION ❑ INDUSTRIAL WASTE GENERATOR ❑ STATIONARY COMPACTOR (20 yd. or greater) HAZARDOUS WASTE GENERATOR INFECTIOUS WASTE GENERATOR ❑ WASTE STORAGE FACILITY ❑ NEW SITE APPLICATION FEE ❑ MIXED WASTE RECYCLING FACILITY ❑ MANURE STORAGE SITE ❑ SITE EXEMPTION APPLICATION VEHICLES AND CONTAINERS (Fill Supplemental Form) ❑ COMPACTOR TRUCK ❑ COLLECTION TRUCK ❑ ROLL -OFF TRACTOR ❑ ROLL -OFF TRAILER (No. to be used dually as Limited Waste Hauler Vehicle) ❑ RENDERING, VEHICLE ❑ MANUER VEHICLE ❑ FERTILIZER VEHICLE ❑ LIMITED WASTE HAULER VEHICLE . ❑ LIMITED WASTE HAULER TRAILER ® 20 + YARD BINS, DUMPSTERS, Roll -off & Other Containers I hereby certify that 1 have prepared his 1*cation and flat to the best APPLICANT'S SIGNATURE X ` No. to be permitted No. to be permitted No. to be permitted No. to be permitted ------------- No. to be permitted No. to be permitted No. to be permitted No. to be permitted No. to be permitted No. to be permitted... X wledge it is true and correct _C Title / /1?r �� Date FOR DEPARTMENT USE ONLY Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan. 1 & Received By Jan. 31 ❑ July 1 & Received By July 31 Received by Date Receipt No. Permit Nos Issuance Date APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered 1601 E. HAZELTON AVE., P. O. BOX 2009 STOCKTON, CA 95201 y BASE EXPLANATION BILLING DATE REMITTANCE i DATE I $ REMITTED AMOUNT DUE REMIT CHECKED AMOUNT FEE FEE LESS PRORATION PLUS PENALTY 1 OTHER OTHER Received by Date Receipt No. Permit Nos Issuance Date APPLICANT—RETURN ALL COPIES TO. ENVIRONMENTAL HEALTH PERMIT/SERVICES Mailed Delivered 1601 E. HAZELTON AVE., P. O. BOX 2009 STOCKTON, CA 95201 y