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Application Will 0rocessed When Properly Completed. Be Sure To Sign To plication. <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 heeby madg to carry on basin ss nder Permit in the junsdic ar a of San Joaquin Local Health District. <br />N Business Name (DBA) Lodi dutpatient surgical Center Address ��� � • Ham Lane, Lodi <br />Towner Lodi Outpatient Surgical Center,Ingiddress 521 S Ham Lane Lodi <br />J Firm Partners, Addresses and Telephone Numbers <br />a Business Telephone No. (209) 333-0905 Emergency Telephone No. (209) 579-7917 <br />Franchise Area Served N/A <br />L Applicants Name (Print) Markl i n E. Brown Title Administrator Date 10/06/88 <br />Please check Applicable Category(s). Fill in the Required Information, Return all 3 copies. <br />Imm <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 />Recti veo <br />Ep <br />OCT 7198,5 <br />ENVIRON <br />rERM1T ISER ALc�SALTy <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 this application and that X to best of my knowledge <br />owledge it is true and correct. <br />APPLICANT'S SIGNATURE <br />X Administrator Date 10/06/88 <br />�- <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 />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 />