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l;•`+:1 tf15j715975 Y PAGE 02/0 GEOCON - EAST BA <br /> �. .I�AT!?REC,EIyEp —— •• rpZE .:ol <br /> SAN JOAQM Cbumy ��,��,.���o�, <br /> ENVIRONMNTAL$EALTH�DEPARTMZNT <br /> s <br /> 304 E Wi ber Ave 3'a Floor Stocimn,CA 95205 <br /> 0 C I {; 09?'49-420 Fax:(209)464-0138 Webc avww.ca.sart j°a4nin c�.uslcbtd <br /> �;•:`;: -:°. _i';-� � p. LIC ACU <br /> : . .° RDS RELEASE A.PPLICA r"ON <br /> APPLicAN7: SUSINSWA0014 : 77 <br /> r <br /> ADDRESS: o <br /> FACsff AX: 7 Z <br /> TENTATWE*APPOINTMENT DATE: TIMM: <br /> (Piea"e all&w 40 busTnen days from dater of appllwtton aubmltl l) <br /> CHECK 8OX TO EXIMMI t REQUEST-$93.90 FEE uv=P §e 3 BUSINESS'DAYS <br /> SIGNATURE OF APPLICANT DATI! td2 <br /> Deparhnent Use Only <br /> 'I"All RBSS UNIT <br /> �. r Nb [3 Unit 1 <br /> G lD ^ <br /> �' 3 5 . ❑ Unit 2 �U ` <br /> s c GO <br /> 9. rne� Io oft a <br /> nree1 M�• ❑ Unit 5 <br /> o. 1 z <br /> ENVIRONWNTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSINO ABATCMENT A SOLID WASTE FACILJTY <br /> OTHER CLI;MUP 8r M(NON-LOP) 0 FOOD FACILITY d SOLID WASTE VEHICU <br /> C UNDERGROUND TANK(moNrroRINGIREMOVAL) 0 POU K1=NNEL 0 DAIRY } <br /> d HAZARDous WASTE Camp-A rOR 17 CHICKEN RANCH I9 PKG TAFRATINENT PLANT <br /> TIERED PERTVIITTo FACTLITY ❑ MOTI MOTEL CI PLWPERTRVCKlYARDtCHEM TO"Ta <br /> TATTocaoDY PIRKOMG 0 POOLISPA 0 LAND USE APPLICATION! r <br /> 0 MI!DIGAL WASTE FACIIJTY lO OTHER(PLEASE SPEGIRY) <br /> 1. List up to ten addresses in the cpace gE7ove. Select the type(S)of files from the list above by checking <br /> the appropriAls box(es), At least ane fele type MUST be selected, fax to 9 4 or mall to the <br /> add_m6s indic.-oted ai2,ve. <br /> 2. EHD will notify the atpplicant If any EHD files Oxist. An appointment for Review will be confirmed <br /> approximately five busineSS days but no latter then ten(10)days after receipt of application. The fllea <br /> will be held for a melxlmum offive business days for review. Appointments should be scheduled <br /> accordingly: <br /> 3. A Me that Is actively being worked on by EHD staff may not be immediatoly available for review. A new <br /> application may be submitted when the fila Is available. <br /> 4. Any file not returned In the sari7e condition as.releasad wilt ba reorganized by EHD staff at the expense.. <br /> of the appl#cant. Future file reviews by tho same SppiiC$ht:may require a$93.00 deposit prior to review. <br /> • *TENTATn appointment dates most be confirmed with HAD staff. <br /> Q., Appilaations received after 3;00 prn will be processed the next business Olay. <br /> CONI=IRM50'APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHON'r FAX INITIALS <br /> REVIEWED YES NO kEVIEW DATE <br />