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ROM : Geo-Phase Environmental. FAX N0. : 2095590295 Oec. 07 2004 12:33PN P2 <br /> EHD LOG NUMBER <br /> DATE RECEIVED SAN OAQUIN COUNTY <br /> ' t1 <br /> G r\ n[ .• �1 i Il'� ENIMONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3rd Floor Stockton,CA 95205 <br /> 7 Q 468-3420 Fac: (209)464-0138 Web:www-00.13a.n joaquin.ca.us/ehd <br /> EF t'i.T HEALTH PITBLIC CORDS RELEASE APPLICA7101 <br /> APPLICANT: d 44,rd BUSINESSIAGEEN.CYy_(/-��/'G�/���� �� <br /> AApRESS��� <br /> PHONE: FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: 1 � <br /> (Please allow 10 business days from date of application sukimil)�"" <br /> CHECK BOX TO EXPEDITE REQUEST-$83.00 FEE-•REQUEST PROCESSED IN 3 BUSINESS DAYS / ? <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> FILE.ADDRESS PUM3 <br /> sty+ it1 <br /> 2. strest G <br /> 3. street <br /> G <br /> t, street <br /> at• <br /> 5. 9trset <br /> 8. Sho¢I nit 4 <br /> 7. Sheet <br /> 8. Street G <br /> a. El Unit 5 <br /> 9. Sveet <br /> ± LL G <br /> ry <br /> 50. Street <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES ; <br /> E7 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) El HOUSING ABATEMENT 0 SOLID WASTEiFA610TY--- ' <br /> 13 OTHER CLEANUP SITF(NON-LOP)OPJ d FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> ❑ DOG KENNEL. ❑ DAIRY <br /> •�T UNOERGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> HAZARDOUS WASTE GENERATOR p MOTEUHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> TIERED PERMITTED FACILITY POOUSPA ❑ LAND USE APPLICATION SITES <br /> 173TAT(OOBO ODY PIERCING 0OTHER(PLEASE SPECIFY) <br /> 11 MEDICAL WASTE FACILITY <br /> 1. List up to ten addresses in the space above. Select the type($) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ten(10)days after receipt of application. The files <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 on by EHD staff may not be immediately available for review. Anew <br /> application may be submitted when the file is available. <br /> 4. Any file not returned in the same condition as released will be reorganized by EMD staff at the expense <br /> of the applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to review <br /> S, *TENTATIVE appointment dates must be confirmed with EHD staff. <br /> g. Applications received after 3:00 pm Will be processed the next business day. <br /> . • • • ... <br /> C01,' RMED Al P001"!TaYIENT PATE ... T•IMfr <br /> DATE CONFIRMEDPHONt . FAX` INITIALS ;------- � <br /> REVIEW DATE. 1 <br /> REVIEWED -..: YES 'NO � . <br /> EHD 0-02-006 <br /> 8f81Z003 <br />