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1014:>� SAM-ABDO PAGE 02 <br /> 4/07/200520:01 . 20994 �� PACS gl <br /> RMMI) SAN JOAQUIN COUNTY f1 1" FF_ <br /> D ' F"MMA"TA3L HEALTH DEPAR LENT <br /> 304 East Faber Avenue,3wd Floor,Stockton,CA 95202�-2708 <br /> An - 2005 Te ePhoxv('209)448-3420 Parc:(209)464-0138 Web:vfnvw•sjgaY.or�lehd <br /> ENV€r O-LAMENT HEALTH UBS R G' R ]S g, ,FA E ADPL CA►'�'XC1N <br /> � � d � Dl3sIN�s3rAGF��`= <br /> AWPUCAr <br /> 41$1!I � � �D �,r•_FRL'r1lNlii•�: Q �. �D� — <br /> ,,g V. Y P Pl: <br /> -TE=NTAMW APPClIWWAT DA"M- Taw. <br /> subirdLW-*Far-*Farm"W"( rip4+K 40 a dAy#�dten of � . <br /> r it x pax To rocp avf=ss. Woo F"(CAS v� �c oN�Y1-R�u�ST�itDc�,s�v a i a Busit4�Ss a►�rs <br /> r' r <br /> SIGNATuRC OF APPLICANT <br /> urirr DrSTRrsUrlgN <br /> t 2 nit 4 unit o b G ollmr(�iearronlrJiist�hra�a61 <br /> FlL.b AQDRI=SS fHo Usra ONLY <br /> sb V0 Naim CRY <br /> 3. �- <br /> 4. ---.� <br /> 5. . <br /> 9. <br /> to <br /> SpecMc Dabs pAW of lnformadon Regtmt Hk Frarn — r <br /> FhMJt:lNfAWTAL�fiMTH DEPARTdILxW M1111 R:**LffVft" <br /> car ,TANK(U"CLEAMWan0.OP) W�� AETtC <br /> WMW <br /> v wen► cMo�+-D TMT&Wz �PL <br /> ;burr %w0 TARK ttSoNtra a+ '"�) °O�„ "Q' "'TP9LK;,slY Toff_vm <br /> = WAM OMWIat prefer• i AtfG umG A kT <br /> mrxbPia�wr�FACns" A <br /> TA �of7Y(' RCEHQ Q *%AAM <br /> [JL vo a.icy ash ins AFZE AvAAlur w+s a abore�t�►cls+cktr tris <br /> 1. Lkt vp Ro ten addra"fas'nth*spm al�ave, select me"(s)of'alas"m� � res <br /> r'I.t b9ges), At[east mo file type MU6T bfa e�cleeted. with�e�4&9" ! <br /> and cat d abov>ff� AdfTr s ranges vrill not be accepted-fbr Additional I/tQrlds y <br /> will be fly next business da - <br /> the EH0.Appli atioms le" after 3.p0 pm p t#or rdv r wll[b4 oorifirrrred <br /> �. The l�Hk7 ill notify this applleant if any EHD�exp. apprrlrit <br /> a [axlniatelntan(io)days s#te►r rpeaiot of app[i on. The <br /> ee WH[ba held for a msXlmum a�f fh►e bnsinsa+e <br /> days f*r mdow. AppolfftOnts shcniltl be scheduled not be l mrr�edlateW avPi[ablQ for reviou►. Anew <br /> 3. A Ella that is"fively tieing worked nn b�►EHb staff My <br /> appliv2*.m nVy lav sum when this ills lf3 ayaiSahte. srll?br?d by EHD staff it the expan��the <br /> require S 1F83.0a depasitpriorto r+avrsW' <br /> 4. Any ftle+wt 're°d in the creme condition its tel4ttrred will e <br /> $pplka�lt Future file ravlg"by Elie same aFPIM may req <br /> ' I <br /> r <br /> slSAAfi <br /> I <br />