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Application 4 Processed When Properly Completed. Be Sure To SigApplication. <br />APPLICATION FOR INSPECTION <br />NO CARBON NECESSARY AND NON -TRANSFERABLE, REVOCABLE, AND SUSPENDABLE SOLID WASTE <br />ENVIRONMENTAL HEALTH PERMIT <br />SOLID WASTE <br />Applicatios hereby m de to c rry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br />O Business Name (DBA) `tWeau 6onyatescent Hospital Address 1221 Rose Marie Lane, Stockton <br />a Owner Beverly Enterprises Address ' ' Shaw Grp , rpcn7CA 93711 <br />J Firm Partners, Addresses and Telephone Numbers — <br />00' Business Telephone No. 477-2664 Emergency Telephone No. <br />Franchise Area Served <br />L Applicants Name (Print) Beyerl pv C ortnpr Title Admi n.istrat or Date6-24—R—RS <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 <br />STATIONARY COMPACTOR (20 yd. or greater) <br />HAZARDOUS WASTE GENERATOR <br />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 <br />COLLECTION TRUCK <br />ROLL -OFF TRACTOR <br />ROLL -OFF TRAILER <br />(No. to be used dually as Limited Waste Hauler Vehicle) <br />RENDERING, VEHICLE <br />MANUER VEHICLE <br />FERTILIZER VEHICLE <br />LIMITED WASTE HAULER VEHICLE <br />LIMITED WASTE HAULER TRAILER <br />20 + YARD BINS, DUMPSTERS, Roll -off & Other Containers <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />------------- <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />I hereby certify that I have prepared this a do that to the best of my knowledge it is true and correct. <br />APPLICANT'S SIGNATURE X L� Title d4tt6/0 <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 />BASE <br />EXPLANATION <br />BILLING <br />DATE <br />REMITTANCE $ <br />DATE REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />$30,00 <br />6.17/85 Du <br />7/17/85 0 -OU <br />30.00 <br />X <br />FEE <br />LESS <br />PRORATION <br />�77f <br />/ % !�57 <br />PLUS <br />PENALTY <br />OTHER <br />OTH,,ERRr <br />��-29 <br />NQ <br />M—�� <br />Received by Date Receipt No. Permit Nos. Issuance Date, Mailed Delivered <br />