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Appllcatio* Processed When Properly Completed. Be Sure To Sop Application. <br />APPLICATION FOR INSPECTION <br />NO CARBON NECESSARY AND NON -TRANSFERABLE, REVOCABLE, AND SUSPENDABLE SOLID WASTE <br />ENVIRONMENTAL HEALTH PERMIT <br />SOLID WASTE <br />Application is hereby made to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br />N Business Name (DBA) Rnana House Convalescent Hospital Address 4520 N. FSDOrado <br />z Owner Beverly Enterprizes Address $71 S. Pa.irnakq B13rdpPasadina CA91W5 <br />a <br />Y Firm Partners, Addresses and Telephone Numbers <br />a Business Telephone No. 477-0271 Emergency Telephone No. Same <br />J Franchise Area Served <br />L Applicants Name (Print) David C. Ormi Gtcnn Jr TitleQ�'^-. traAar Date 6-26-85 <br />Please check Applicable Category(s). Fill in the Required Information, Return all 3 copies. <br />SOLID WASTE DISPOSAL SITE, NO. 39 -AA - <br />NEW SITE PERMIT <br />SOLID WASTE TRANSFER STATION <br />INDUSTRIAL WASTE GENERATOR <br />STATIONARY COMPACTOR (20 yd. or greater) <br />HAZARDOUS WASTE GENERATOR <br />INFECTIOUS WASTE GENERATOR <br />WASTE STORAGE FACILITY <br />NEW SITE APPLICATION FEE <br />MIXED WASTE RECYCLING FACILITY <br />MANURE STORAGE SITE <br />SITE EXEMPTION APPLICATION <br />VEHICLES AND CONTAINERS (Fill Supplemental Form) <br />❑ COMPACTOR TRUCK <br />R COLLECTION TRUCK <br />❑ ROLL -OFF TRACTOR <br />❑ ROLL -OFF TRAILER <br />(No. to be used dually as Limited Waste Hauler Vehicle) <br />❑ RENDERING, VEHICLE <br />❑ MANUER VEHICLE <br />❑ FERTILIZER VEHICLE <br />❑ LIMITED WASTE HAULER VEHICLE <br />❑ LIMITED WASTE HAULER TRAILER <br />❑ 20 + YARD BINS, DUMPSTERS, Roll -off & Other Containers <br />No. to be permitted <br />No. to be permitted —� <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />No. to be permitted <br />I hereby certify that I have prepared t appl' at' n tha the best of my knowledge it is tru and correct. <br />APPLICANT'S SIGNATURE x Title Date 4/1/.;? �J <br />FOR DEPARTMENT'USE ONLY <br />Fee Is. Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ HOURLY ❑ Jan. 1 & Received By Jan. 31 ❑ July 1 & Received By July 31 <br />BASE <br />EXPLANATION <br />BILLING <br />DATE <br />REMITTANCE <br />DATE <br />$ <br />REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />�,/'`� <br />3p. W <br />O -C)o <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 />