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Application Wit0 -1 �:�rocessed When Properly Completed.Be Sure To Sign pplication. <br /> C5 <br /> APPLICATION FOR INSPECTION 11 <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 /> y Business Name(DBA) Valley Gardens Health Care Center Address 1517 Knickerbocker Dr- , Stockton, CA 95210 <br /> , owner Hillhaven Corporation Address 1143 Broadway Plaza, Ste- 400, Tacnma,WA 98409 <br /> a <br /> j Firm Partners,Addresses and Telephone Numbers <br /> R Business Telephone No. 209-957-4539 Emergency Telephone No. Same <br /> Franchise Area Served San Joaquin County <br /> L Applicants Name(Print) JO Ann Steinmetz Title Administrator DateApril , 1989 <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 /> El STATIONARY COMPACTOR(20 yd.or greater) PAYMENT <br /> ❑ HAZARDOUS WASTE GENERATOR RECEIVED <br /> INFECTIOUS WASTE GENERATOR <br /> Fe, 7 � <br /> WASTE STORAGE FACILITY N Ei r <br /> ❑ NEW SITE APPLICATION FEE <br /> ❑ MIXED WASTE RECYCLING FACILITY tNVIRONMENTAL HEALTH <br /> ❑ MANURE STORAGE SITE PERMITISERVICES <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 /> 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 prepared this application and that to the best of my knowledge it is true and correct. <br /> /�11��� �� <br /> APPLICANT'S SIGNATURE X wvvr� Title Administrator Date 4-1 2—RR <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 <br /> PENALTY <br /> OTHER <br /> OTHER �O V <br /> ived 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 />