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" UL <br /> ♦..l� rvirxl�+U It'.YAC 1 - <br /> une.MLC0IYW � � EnV L4U>•UMUEIi <br /> $AN*QUIN COUNTYPUBLIC HEALTH SER ICES <br /> , N' IRONMENTAL HEALTH DIVISION <br /> EAST WESER AVENUE,THIRD FLOOR ( �/r/�� <br /> \ <br /> Rs 'OCKTON CA 95202 ( <br /> 8-3420 <br /> t^� PUt3LlIC RECORJ PELEASE APPLICATION ; <br /> APPLICANT <br /> r'4iS-Nr�f� t/,jy6.pr7 DIfSINtsS1A,G}ENCY Shtlydl-E ,17�r�y 'Y`IIC�S <br /> ADDRESS 1 SSI IAS T7✓ H!NG1��}_ 7�OU I-�a A-�' 'y / <br /> PHONE -F-AGSIMU-1; <br /> TENTATIVE`APPORiTMENT DAT[ TIME _- <br /> {Pfei4ty[Ne T ro 10 buolnasa e�y�teem quo gtappifc?Uon s�bmRtalj <br /> XCHECK BOJ(TO EXPEDITE REQUEST-373.90 FEE—REQUEST PROCeSSCO IN 3 DUS11NE55 RAYS <br /> SIGNATURE OF APPLICANT _ -��� `.J&.t.2L- DATE <br /> RrE ADDRESS 7108 2109 9AD STAFO USE ONLY <br /> PAOGRAM ELEMENTS SEARCn <br /> 1 OI g!;-T CHf)-eT�R U A`-/ <br /> ) Perp �ASJ_„ cl�rgrz[�i? So J"Sy i s C1 ' , <br /> 1 C>4 <br /> ra y > c. 12 Gui1 a co • )0 <br /> A77 -174 <br /> lIt.' F R CU Z.U�� <br /> it <br /> ENVIRONMENTAL HEALTH DIVISION FUSS <br /> P�UNDERGROUND TANK(VST)CLEANUP SITE(LM O HOUSINO ASAYMAENT a 50LID WASTE FACILITY <br /> -( OTHER CLEANUP SITE(NON{OP) t7 FOW FACILITY Cj $QUO WASTE VEHICLE <br /> UNDERGROUND TANK(MONtTOttINO1KEM0yAI) G DOG KENNEL 0 DAIRY <br /> KA7ARDOUS WASTE GENERA-MR O CHICKEN RANCH 0 PKG TREATMENT PLANT <br /> 4 TIPJrrD PERMnTEO FACA.TTY 0 MOTEUNO'TE1. ❑ PUMPER TRUCK/YAROCNEM TOILETS <br /> Cl TATTOOIB00Y PI:KCIN4 C3 P0009PA 0 LAND USE APPLICATION SITES <br /> ❑ MEDICAL.wASYE FACMMY ❑ PUBLIC WATER SYSTEM CT OTHER(PLEASE;SPEGIFY ABOVE) <br /> 1. List up to ton addresses in the*Pace above. Select the types)of files from the list above by checking <br /> ffia approprfatc box(aa). At least ono fife typo MUST be solected. Fax to GVJ 464:01SB gr mail t_g the <br /> address inditaLd Bbeva <br /> 2. END will notify the applicant H airy ERD plea exlaL An appointment for review will be confirmed <br /> approximately five business,days but no later than ten(19)days After receipt of applicat10n. The files <br /> will be hold for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A fife that Is actively being WOrked on by EHO staff may not be immediately avajtable for review. A new <br /> apptiration may be submttted when the file IS available. <br /> 4. Any rale not returned In the same condition as released Will be reorganized by EHD staff at the expense <br /> Of tha applicant. Future flit reviews by the same appiitant may require a i76-00 deposit prior to review. <br /> 5. TENTATIVE Appointpent dates must be Confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed rho next IYUS(neVs day. <br /> CONFIRMED APPOINTMIENTDATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW 4ATE <br /> FN m t� app — <br /> TOTAL P.02 <br />