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Applicatio*Be Processed When Properly Completed. Be Sure To S*e Application. APPLICATION FOR INSPECTION NO CARBON NECESSARY AND NON -TRANSFERABLE, REVOCABLE, AND SUSPENDABLE ENVIRONMENTAL HEALTH PERMIT SOLID WASTE SOLID WASTE Application is hereby made to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. rn Business Name (DBA) Tracy Community Memorial UPSi tal Address 1420 N. Tracy Blvd- I- Community owned Address Same a J Firm Partners, Addresses and Telephone Numbers a Business Telephone No. 209 835-1 5nn Emergency Telephone No. 835-1500 Franchise Area Served Tracy L Applicants Name (Print) TPrry Mark Title nim strate Date May 14, 1985 Please check Applicable Category(s). Fill in the Required Information, Return all 3 copies. ❑ SOLID WASTE DISPOSAL SITE, NO. 39 -AA - BASE 0 NEW SITE PERMIT REMITTANCE DATE ❑ SOLID WASTE TRANSFER STATION REMIT CHECKED AMOUNT ❑ INDUSTRIAL WASTE GENERATOR 12 STATIONARY COMPACTOR (20 yd. or greater) ❑ HAZARDOUS WASTE GENERATOR FEE La INFECTIOUS WASTE GENERATOR on premises'. When material leaves premises it is ❑ WASTE STORAGE FACILITY non-infectious. ❑ NEW SITE APPLICATION FEE ❑ MIXED WASTE RECYCLING FACILITY ❑ MANURE STORAGE SITE ❑ SITE EXEMPTION APPLICATION VEHICLES AND CONTAINERS (Fill Supplemental Form) ❑ 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 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 application and that to the best of my knowledge it is true and correct. APPLICANT'S SIGNATURE X Title Admin strator Date May 14, 1985 Q 11 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�� FEE C041— LESS PRORATION PLUS PENALTY OTHER OTHER Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered •nm ,r•ur e 1 m Al , -01— — ruvmnuuruT•, ur•I ru n ,. — nn.. cr,...vt..., n. n...,..