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Application W11 Processed When Properly Completed.Be Sure To Sign Mallon. <br /> APPLICATION FOR INSPECTION <br /> NO CARBON NECESSARY AND NON-TRANSFERABLE, REVOCABLE,AND SUSPENDABLE SOLID WASTE <br /> ENVIRONMENTAL HEALTH PERMIT <br /> SOLID WASTE <br /> Pt� IG DDRESS• e � ACACIA • <br /> Application is hereby made to carry on business under Permit Is aT1 aq cal Dui+ <br /> Or Business Name(DBA) KATSER PERMANENTE MEDICAL OFFTAQfis 1305 TOMMYDON STREET. S TON <br /> i Owner_THE KAISER PERMANENTS MEDICALAd&RQUP 1924 BROADWAY, OAKLAND, CA 94612 <br /> C <br /> S2 Firm Partners,Addresses and Telephone Numbers ADDRESS AS ABOVE (415) 987-3141 <br /> I'LL Business Telephone No._( 209 )476-2000 Emergency Telephone No.( 209) 476-3300 <br /> Franchise Area Served NORTHERN CALIFORNIA <br /> L Applicants Name(Print) 4OHN C. FARRELL Title ADMINISTRATOR Date 03-09-89 <br /> Please check Applicable Category(s).Fill in the Required Information,Return all 3 copies. <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION <br /> ❑ INDUSTRIAL WASTE GENERATOR PAYMENT <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) R m(:Gi i v 9 0 <br /> ❑ HAZARDOUS WASTE GENERATOR MAR <br /> nN" l 1/ 1�J <br /> D1 INFECTIOUS WASTE GENERATOR <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE ENVIRONMENTAL HEALTH <br /> ❑ MIXED WASTE RECYCLING FACILITY PERMITISERVICES <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, <br /> - - - - - - - - - - - - <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 prepared <br /> s appl'cation what to the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE X TitleDate <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 REMITTED AMOUNT <br /> FEE ``. So Oc) <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <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 />