Department of Environmental Resources

FOR PERMIT TO COLLECT, TRANSPORT, USE OR DISPOSE OF REFUSE, INCLUDING:

INDUSTRIAL REFUSE.  REF:  STANISLAUS COUNTY CODE, TITLE 9, ARTICLE 1

PLEASE COMPLETE ALL APPLICABLE QUESTIONS.  (IF ADDITIONAL SPACE IS

NEEDED TO COMPLETE ANSWERS, USE THE SPACE PROVIDED AT # 1 3)

1. Name of applicant(s)

Phone FAX

2. Home and business addresses

3. Mailing address (If different than above)

4. Trade and/or firm name

5. 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 and permanent addresses of all stockholders and the officers, and their percentage of participation

6. Explain the manner in which you will perform the activity for which the permit is requested

7. Do you own or have under your control, in good mechanical condition, sufficient equipment to adequately conduct the business for which a permit is requested? (list equipment below).

8. List the total number, size, type and license numbers of trucks and equipment used in conducting the activity for which the permit is requested

9. List all locations where refuse is collected

10. List all locations (addresses and assessor's parcel numbers) where refuse is disposed of or used; list names(s) of property owner(s).  (If the property owner is not the applicant, written authorization from the property owner is required.)

11. List type of refuse and the total daily amount (by weight) of refuse collected,

transported or used

12. If you receive fees from a refuse producer for collecting or transporting refuse, explain the arrangements by which the fees are determined and also state the amount of the fees collected

13. Additional space needed for comments

I AGREE 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

SIGNATURE

TITLE DATE

CORPORATIVE SEAL