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FROMD:EENqEq) iTOIRAcY, CA <br />0 FAX NO. : 209-935-0675 <br />It. 10 2004 03:19PM P2 <br />D REC.EIVtU SAN JOAQUIN COUNTY <br />FI <br />P' ENVIRONMENTAL HEALTH DEPARTMENT <br />DEC 1 2 304 ) Weber Ave V Floor Stockton, CA 95205 <br />) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br />ENVIR(;i,i.�:Jdiric,7LFH <br />PFPa,, ".FRVICFS PTJ13I IC IZECORbS RELEASE APPLICATION <br />APPLICANT: CAS Y 1EMS A BUSINESSlAGENGY: EA) 6E0 IA; <br />ca��„r. <br />ADDRESS: <br />PHONE: X09" $ss'a6Lt1 FACSIMILE: ?09'$35"QI��� �"-"- I -T - ,• J <br />TENTATIVE' APPOINTMENT DATE: ASAR Time: _ 1.130ANJ <br />(Please allow 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQUEST -$93.00 FEE.- REQUEST PROCESSED IN 3 BUSINESS DAYS / <br />SIGNATURE OF APPLICANT /��Yn Com_ DATE '6l �ey <br />.41 Department Use Only <br />rI II_ <br />P"3r 'JET <br />r{w gas- <br />�'6� <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNIT <br />Unit 1 <br />Unit 2 <br />lliln -! <br />D� Unit 5 <br />NDERGROUND TANK (UST) CLEANUP SITE (LOP) HOUSING ABATEMENT OLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) ,y - FOOD FACILITY SOLID WASTE VEHICLE <br />TIERED PERMITTED FAEL <br />>!rUNDERGROUND TANK CILITY "I <br />/"CDAJRY <br />HICKEN RANCH 1,p TRD USE UAPPLICATION SITESATMENT PLANT HAZARDOUS WASTE GENERATOR e TEUHOTEL <br />0 TATTOOIBODYPIERCING �OOUSPA <br />WASTE FACILITY Cl OTHER (PLEASE SPECIFY) <br />MEDICAL <br />1. List up to ten addresses in the space above. Select the type(s) 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. A new <br />application may be submitted when the file is available. <br />4. Any file not returned in the some condition as released will be reorganized by EHD 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 />5. `TENTATIVE appointment dates must be confirmed with EHD staff. <br />S. Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED APPOINTMENT DATE <br />DATE CONFIRMED <br />REVIEWED YES <br />dw = <br />NO <br />TIME <br />PHONE . FAX INITIALS' <br />REVIEW DATE <br />FILE ADDRESS <br />% <br />G <br />iilP /% S <br />2. <br />SVCJ <br />00 <br />O <br />cc <br />70G <br />s. <br />a. <br />Svat <br />Snore 2 $ 0 <br />LOO <br />NN <br />o <br />% O <br />O <br />CIN <br />7pDL-I2!%V <br />s. <br />svw <br />do <br />0 4 <br />pl <br />Kaar✓ <br />6 <br />no <br />Ci <br />7. <br />Sire?t <br />B. <br />Sveet <br />d <br />9. <br />SVe2l <br />Q <br />�0 <br />SVee� <br />G <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNIT <br />Unit 1 <br />Unit 2 <br />lliln -! <br />D� Unit 5 <br />NDERGROUND TANK (UST) CLEANUP SITE (LOP) HOUSING ABATEMENT OLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) ,y - FOOD FACILITY SOLID WASTE VEHICLE <br />TIERED PERMITTED FAEL <br />>!rUNDERGROUND TANK CILITY "I <br />/"CDAJRY <br />HICKEN RANCH 1,p TRD USE UAPPLICATION SITESATMENT PLANT HAZARDOUS WASTE GENERATOR e TEUHOTEL <br />0 TATTOOIBODYPIERCING �OOUSPA <br />WASTE FACILITY Cl OTHER (PLEASE SPECIFY) <br />MEDICAL <br />1. List up to ten addresses in the space above. Select the type(s) 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. A new <br />application may be submitted when the file is available. <br />4. Any file not returned in the some condition as released will be reorganized by EHD 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 />5. `TENTATIVE appointment dates must be confirmed with EHD staff. <br />S. Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED APPOINTMENT DATE <br />DATE CONFIRMED <br />REVIEWED YES <br />dw = <br />NO <br />TIME <br />PHONE . FAX INITIALS' <br />REVIEW DATE <br />