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X714 4Uli NUAIBEH <br /> SAN AQUIN COUNTYPUB IC HEALTHoe�RVICES <br /> NVIRONNIENTAL HEALTH DIVISII N <br /> FC, I V� WEBER F FST STOCKTON C 95 02 FLOOR <br /> (209)4684 420 <br /> FEB 2PUKIC RECORDS REL ASE APPLICATION <br /> a� Lrcaxi �" �E LSH BUSINESSIAGEN "JA, <br /> tip,I <br /> ADDRESS i <br /> PHONE - FACSIMILE- - <br /> TENTATIVE*APPOINTMENT DATE ZTIME -- CCX-�'� <br /> (please give 7 to 10 business days trogn date of application submittal) <br /> MCHECK BOX TO EXPEDITE BEQUEST-$78.00 FEE•-REQUEST PR ESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> 71� FILE ADDRESS <br /> i)�jpil&l Ai <br /> O� 1 I <br /> W 4� <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> W U' NDERGROUKD TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING AF ATEMENT 0 SOLID WASTE FACILITY <br /> dJOTHER CLEANUP srrF(NON-LOP) 0 FOOD FACIL TY 0 SOUL)WASTE VEHICLE <br /> WUNDERGROUNDTANK EMONITOFUNGIREMOVALI L7 DOG KENNE 0 DAIRY <br /> d HAZARDOUS WASTE GENERATOR a CHICKEN NCH 0 PKG TREATMENT PLANT <br /> 13 'nERED PERMITTED FACILITY O MOTELJHO L 0 Pl)MPERTRUCKfYARD1CHE01 TOILETS <br /> 0 TAITOOIBODY PEIRCING ❑ PO(ILISPA 0 LAND USE APPLICATION SITES <br /> ❑ MEDICAL,WASTE FACILFTY ❑ puBLIG WA IER SYSTEM a OTHER(PLEASE SPECIFY ABOVE} <br /> 1. List up to ten addresses in the space above. Se! ct the type(S)of files frorrl the list above by checking <br /> the appropriate boxes). At least one file type MUST be selected. Fax (201464-0138 or ma-ml to <br /> th <br /> address indicateO above <br /> 2. EHD will notify the applicant if any EHD files axis L An appointment for review will be confirMed <br /> approximately five business days but no later than ten(10) days after receipt of application. The filar <br /> will be held for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A file that is actively being worked an by EHD at ff may not be immediately available for reviow. A new <br /> application may be submitted when the file is av illable. <br /> 4. Any file not returned in the same condition as re eased will be reorganized by EHD staff at the expense <br /> of the applicant. Future file reviews by the sarne applicant may require a$78A0 deposit prior to review. <br /> g, 'TENTATIVE appointment dates must be confVff ied with EHD staff. <br /> 6. Applications received after 3.04 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES `NO REVIEW DATE <br /> EH 00 ii ulm <br />