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• Application]be Processed When Properly Completed.Be Sure To 40 <br /> Application. <br /> APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> DELTA VALLEY CONVALESCENT HOSAM WASTE <br /> Applicatio�nX* hereby made to carr on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br /> N Business Name(DBA) In�y �a` �tX `7 Address- 1032 N. Lincoln St. , Stockton <br /> z owne,Al & Toni Johnson Address 11514 Benndorf Road, Acampo, CA 95220 <br /> J Firm Partners,Addresses and Telephone Numbers same <br /> a Business Telephone No. 209-466-5341 Emergency Telephone No. 209-368-8649 <br /> Franchise Area Served Stockton <br /> L Applicants Name(Print) Al Johnson Title Admi ni strator/OwneSate 7-15-85 <br /> Please check Applicable Categoryll 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 /> j ❑❑ HAZARDOUS WASTE GENERATOR <br /> Xly,.l 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 <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 /> ❑ 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 preppare Is cation d that to the best of my knowledge't is true and correct. <br /> APPLICANT'S SIGNATURE X Title Datefl <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan.1&Received By Jan.31 ❑ July 1&Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTEDAMOUNT <br /> FEE y <br /> FEE I /` <br /> LESS -- T_-- <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Q= -7/1 <br /> Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />