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Appllcatlon @aocessed When Properly Completed. Be Sure To Sl0plication. APPLICATION FOR INSPECTION NO CARBON NECESSARY AND NON -TRANSFERABLE, REVOCABLE, AND SUSPENDABLE SOL0TE 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. y Business Name (DBA) Gross Convalescent HOSPital Address 321 W. Turner Rd. Lodi, Ca. 95240 z Owner Rev. Oscar Gross R. N. Address 321 W. Turner Rd. Lodi, Ca. 95240 a J Firm Partners, Addresses and Telephone Numbers aBusiness Telephone No. (2 0 9) 334-3760 Emergency Telephone No. Franchise Area Served LApplicants Name (Print)_RL--v- Os r (;roses_ R_ N_ Title Administratnr Date 5-22-85 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 ❑ 20, YARD BINS, DUMPSTERS, Roll -off & Other Containers No. to be permitted I hereby certify that I have p :epared .this application-that4olte best of my knowledge i t e and correct. APPLICANT'S SIGNATUR-----—'' ' Title Date /f 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 VEHICLES AND CONTAINERS (Fill Supplemental Form) BASE ❑ COMPACTOR TRUCK No. to be permitted ❑ COLLECTION TRUCK No. to be permitted ❑ ROLL -OFF TRACTOR No. to be permitted ❑ ROLL -OFF TRAILER No. to be permitted (No. to be used dually as Limited Waste Hauler Vehicle) ------------ ------------- RENDERING, VEHICLE RENDERING, No. to be permitted ❑ MANUER VEHICLE No. to be permitted ❑ FERTILIZER VEHICLE No. to be permitted ❑ LIMITED WASTE HAULER VEHICLE No. to be permitted ❑ LIMITED WASTE HAULER TRAILER No. to be permitted ❑ 20, YARD BINS, DUMPSTERS, Roll -off & Other Containers No. to be permitted I hereby certify that I have p :epared .this application-that4olte best of my knowledge i t e and correct. APPLICANT'S SIGNATUR-----—'' ' Title Date /f 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 BASE EXPLANATION BILLING DATE REMITTANCE DATE $ REMITTED AMOUNT DUE REMIT CHECKED AMOUNT FEE ✓0-dil FEE LESS PRORATION PLUS PENALTYV� ii e Z 12- 1 U` A OTHER OTHER Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered