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Application # Processed When Properly Completed. Be Sure To Sig0 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 herebmade to carry on business under Permit in the jurisdiction area of San Joaquin Local Health District. <br />H Business Name (DBA) Lodi Aemori al Hospital Add2s 975 S. Fairmont Ave., Lodi <br />aOwner {° + �� Address — Aa/ <br />Y Firm Partners, Addr . es d Telep one Numbers <br />$ Business Telephor>o �� Emergency Telephone N ^ '� <br />r <br />Franchise Area Served h <br />L Applicants Name (Print) Title Date <br />Please check Applicable Category(s). Fill in the Required Information, Return all 3 copies. <br />low <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 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 />❑ <br />RENDERING, VEHICLE <br />No. to be permitted <br />❑ <br />MANUER VEHICLE <br />No. to be permitted <br />❑ <br />FERTILIZER VEHICLE <br />No. to be permitted <br />❑ <br />LIMITED WASTE HAULER VEHICLE <br />No. to be permitted <br />❑ <br />LIMITED WASTE HAULER TRAILER <br />No. to be permitted <br />5a 20, YARD BINS, DUMPSTERS, Roll -off & Other Containers No. to be permitted <br />I hereby certify that I have prepared Ztpl a 'o4an Lthe y knowledge it is true and correct. <br />APPLICANT'S SIGNATURE X Title Administrator <br />If <br />Date 6/24/$5 <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 REMITTANCE $ <br />DATE DATE REMITTED <br />AMOUNT DUE <br />REMIT <br />CHECKED <br />AMOUNT <br />FEE <br />FEE <br />i <br />3�" C) C) <br />LESS <br />PRORATION <br />Ck.` �7 z7 <br />PLUS <br />PENALTY <br />OTHER <br />OTHER <br />Received by Date Receipt No. Permit Nos. Issuance Date Mailed Delivered <br />