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11/19/2003 11:20 464613t <br /> DATE RECE1Ven E)wU'IRR'$ 1iAL. I-J,.16 <br /> PAGE 01 <br /> �_. �i' h PAW <br /> COUNTY L"u wt;vli+wutw <br /> Esti�TItON <br /> MENTAL MALT$DEPARTKF <br /> NO V9 304 E A'ebe(Ave Y4 Floor 5toc1�•tprl, Cry 95245 <br /> 1 200 8 342o xar:(209)4W13s Web. <br /> ' vww,co.san joaquin.ca.uslchd 1 ,J <br /> l iVV1(iUnln�Efd7 ii( , I'IT$T,IC 12T <br /> APPLiCAAfT: >( 7`NLEE7J CORDS RELEAS)EAPPLICATION <br /> f�Il SGH ACr r N617ySSE55M <br /> ADDREss: t� . o — �"susnlEss! NA <br /> TrrKrATIVE 'APFOAVTMEIrT DAW- � ^' <br /> (Plcam alltav 70 bus/vew".'tram die W <br /> N�PPf 1Y+Ibn:u6minat) <br /> CR epXroExt'EutrErlrcaiEsr.S.noom-0XtwK9,r . <br /> sIGNATUREOF-APPL.IGAwr - aRDCEssEorNY]y{rglNpY,S17AYi <br /> PILE AUDRJ6B �6'"'1T1O^t lms Or+v <br /> I vnrr <br /> ❑ Unit t <br /> t� 552 flS Unit3 IGIc � <br /> UDI,Jr <br /> EN11RONMENTAL WEALTH U I D 1 3(,63 <br /> NOERGROUND TA&KIIMT)CLWQp Srrfs(LOP) <br /> td' OTHER CLEANUP-srm jwm.L I6 NOUDA(G <br /> �ufar naNaurrtrTwlrclFiGWiro�ia aDoonP CI'SpLypIiASTEVMOCYV.::_; <br /> I'aG/IUTJMovAL1 a Doc KFiUL ' a 'sos•m 1i/A9TE vP�I1CLq <br /> _�1AXAIt1)4U^ <br /> WASTE GENERATOR O GfecKEN In DAGn ' <br /> ® TIERED P UrroM-N MMEO FACILITY- p-MDTELlr1D O PKG TREATMENT PLlWT <br /> ef.MEDICAL AIsTEooy ��timPOG)LISPA.. 4 P"p"TRUGKrrARMGNEM TDILETS <br /> O OTMR IPLEASE SPeclrl'L t rta uaEAa:PLtw'IYaN sorts <br /> �. List up to ten addresseY In the ayaca above geipct <br /> Ute appropriate box(ea). AC least One filetypeMUST be sefected,f FAX f2 6109 from a list aboye py checking <br /> adder+^11101"ted*b )441-01sa or.n 'r r a.� <br /> 2. EHD will nOWY the applicant If any END filo;oxist An appointment far mvlgW will he confirmed <br /> 2PProxhataly ffva busrin=flays but no later than ten(10)days atter receipt of application. "rhe files <br /> will be held for a maximum of five buaine9 days tar review_ Appalntments should he scheduled <br /> $. <br /> accardingty, <br /> A file alar!s actively ODing woritod an by Elip staff may no[be immediately available torroview A rtew <br /> application maybe=ubmittird wtlon Oho me�avaifahle, <br /> +1. AnyfilOttat raturrrodtnifee same camdi'fiOn as:Tpleased ardt!6a raOr'ganired_9rji>"1-Ib yiaff'st the expense <br /> Of the applfclutL Futuce filareviavra try tha same applicant may rngr,irty a�g�pl! prior to reviow. <br /> �. 'TENTATIVE appointmarit dates must he ccn4innad acith EHD stair: <br /> b• APP11GdtioDS racairad after 3:00 pm will be proccaGad the n@xt husinest'day, <br /> CQNFiRMED APPQiNTAdENf UA7E 7iME <br /> DATE CONFIRMED) <br /> PHONE FAX <br /> tNrrL4Ls <br /> a2�VlE9NEo YES NO REVIEW DATE <br /> maam <br /> TB 39vd <br /> SE9TSEbSTb 10:00 COOL/TT/11 <br />