FOR RENEWAL OF PERMIT TO USE FOOD PROCESSING RESIDUE REF: STANISLAUS COUNTY CODE, TITLE 9, ARTICLE I

PLEASE COMPLETE ALL APPLICABLE QUESTIONS. (IF ADDITIONAL SPACE IS NEEDED TO COMPLETE ANSWERS, USE THE OTHER SIDE OF THIS APPLICATION).

1. Name of applicant(s) Phone

2. Home and business address

3. Mailing address (If different than above)

4. Site Location

5. Trade and/or firm name

6. IF a joint venture, partnership or limited partnership, list the names of all partners and their percentage of participation and their permanent addresses; if a corporation, list the names & permanent addresses of all stockholders and the officers, and their percentage of participation

7. If there have been any changes in operation at your site, please describe on the reverse of this application.

I AGREE TO OPERATE MY SITE IN CONFORMANCE WITH THE PLAN OF OPERATION ON FILE WITH THE DEPARTMENT OF ENVIRONMENTAL RESOURCES, TO COMPLY WITH ALL PROVISIONS OF THE STANISLAUS COUNTY CODE, TITLE 9, ARTICLE I AND ALL CONDITIONS IMPOSED BY THE DEPARTMENT OF ENVIRONMENTAL RESOURCES; AND I CERTIFY UNDER PENALTY OF PERJURY THAT ALL INFORMATION, STATEMENTS AND REPRESENTATIONS SET FORTH IN THE FOREGOING APPLICATION ARE TRUE AND CORRECT.

FIRM SIGNATURE

ADDRESS TITLE DATE

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TITLE DATE

FORM393 4-92

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