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Application a Processed When Properly Completed. Be Sure To SI Application. APPLICATION FOR INSPECTION NO CARBON NECESSARY AND NON -TRANSFERABLE, REVOCABLE, AND SU DABLE SOLID WASTE 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) OAMERON HOSPITAL Address 525 W. Acacia St. Stockton 95203 i owner Dameron Hospital Assn. Address 523 W. Acacia St Stockton,Ca 95203 JFirm Partners, Addresses and Telephone Numbers Non Profit Corp C Business Telephone No. {209) 944 5550 Emergency Telephone No. camp J Franchise Area Served L Applicants Name (Print) Curtis Janssen Title Saf pty of f i r pr Date5-14—A5 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 A I hereby certify that I have prepared this ap I' ion a that to the best of my knowledge it is true and correct. APPLICANT'S SIGNATURE X Title Safety OffiCer Date 5-14-85 FOR DEPARTMENT USE ONLY Fee Is Due: 11ANNUALLY ❑ 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 prepared this ap I' ion a that to the best of my knowledge it is true and correct. APPLICANT'S SIGNATURE X Title Safety OffiCer Date 5-14-85 FOR DEPARTMENT USE ONLY Fee Is Due: 11ANNUALLY ❑ 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 FEE LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered —APPLICANI—RETURN ALL COPIES TO: ENVIRONMENTAL REA0I'1 PERMINSERVICE0 IWIE.HALELIVNAVE.,r.V.OVAAWD alv1ft1V1.,VI