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Applicationa Processed When Properly Completed.Be Sure To Sig a Application. <br /> 9 <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 businesq under PerrpiQLi the jurisdiction area of San Joaquin Local Health District. <br /> Ir <br /> usiness Name(DBA)Kaiser Permanente Medical orr'CRAress1305 Tommydon street, Stockton <br /> wnerKaiser Permanente Medical GrO'ARdress Same 2i0-33b4 <br /> rm Partners,Addresses and Tele hone Num¢ers _usiness Telephone No. 47E-10 0 0 E ergency Telephone No. p���a6anchise Area Served Kaiser Health Plan Members-Stockton Area. <br /> 1987 <br /> pplicantss Name(Print)John Farrell Title Assist. Actmin. Date <br /> Please check Applicable Category(s).Fill in the Required Information,Return all 3 copies. <br /> ❑ SOLID WASTE DISPOSAL SITE,NO.39-AA- <br /> 0 NEW SITE PERMIT <br /> ❑ SOLID WASTE TRANSFER STATION <br /> ❑ INDUSTRIAL WASTE GENERATOR <br /> ❑ STATIONARY COMPACTOR(20 yd.or greater) v <br /> ❑ HAZARDOUS WASTE GENERATOR <br /> INFECTIOUS WASTE GENERATOR ENv�RpM 1SER0�G <br /> ❑ WASTE STORAGE FACILITY <br /> ❑ NEW SITE APPLICATION FEE <br /> ❑ RECYCLING FACILITY <br /> MANURE STORAGE SITE -A1P / F ► <br /> ❑ SITE EXEMPTION APPLICATION �P SO- <br /> VEHICLES <br /> O- <br /> VEHICLES AND CONTAINERS(Fill Supplemental Form) ` <br /> ❑ COMPACTOR TRUCK No.to be permitted <br /> ❑ COLLECTION TRUCK No.to be permitted <br /> ❑ ROLL-OFF TRACTOR No.to be permitted <br /> ❑ ROLL-OFF TRAILER No.to be permitted <br /> (No. to be used dually as Limited Waste Hauler Vehicle) - - - - - - - - - - - - - <br /> RENDERING, <br /> - - - - - - - - - - - - <br /> RENDERING,VEHICLE No.to be permitted <br /> ❑ MANUER VEHICLE No.to be permitted <br /> ❑ FERTILIZER VEHICLE No.to be permitted <br /> ❑ LIMITED WASTE HAULER VEHICLE No.to be permitted <br /> ❑ LIMITED WASTE HAULER TRAILER No.to be permitted <br /> ❑ 20+YARD BINS,DUMPSTERS,Roll-off&Other Containers No.to be permitted <br /> I hereby certify that I have pr ared t ap icatio that to the best of my knowledge it is true and correct. <br /> APPLICANT'S SIGNATURE TitIeASS1St. Administrq�atpr <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 /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS �PENAETIES IILL BE ADDED AFTER DUE DATE SHOWNBE,OW <br /> PENALTY <br /> OTHER 60 DAYS 25 o of BASE FEE <br /> OTHER 90 DAYS. 2576 o#,SAS <br /> Received by Date Receipt No. Permit Nos Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.BOX 2009 STOCKTON,CA 95201 <br />