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" - a_-.... - o'. <br /> . _._ _ .M 1�lJ 1'1Cwf 1 Yui �_•.�•li.. <br /> vw C.K1:Lt1Y W tnV LIIG><Ui�BF32 <br /> nn $AN'*dAQUIN COUNTYPUBLiC HEALTH $ACES <br /> �► D�' ENVIRONMENTAL, HEALTH WISION <br /> EAST WESER AVENUE,THM FLOOR <br /> �IOCKTH]TtA;i5202 <br /> �", <br /> PIL BLIC RE t� �iL�A,SE APPLICATION <br /> APMACANT f�s 1 T'y l~6H 0_� 4�D f� rx va sslxGENcr 1-1! T-d1-C M L�Y��j t•:( f Com`S <br /> PHOINE cac �5_ FAC IMiI 13 !a <br /> TENTATIVE*,kr►Romc mExT DA-rt TIMC <br /> (P1ea%1t Q1'd 7 to 14 bUtInoLL drys fra,n-A da#'a 4I appdc?Gon ssobenittgl) <br /> CHECK BOX TO EXPEDITE RaQIJ45T-478.0 FEE REQUEST PROCeS3:1)IN 7 BUSINESS WAYS <br /> SIGNATURE OF APPLICANT ___ T.=c���`1041L- DATE _ 3--D-A-0"t7 <br /> _Y <br /> FILE ADDRESSUM 51 S_T'W USE ONLY <br /> (� /+1,.,�f] p ft-1 f 1lOc3RAtt1 E4E>IAH�HTS SEAftGtt <br /> 1 G>I '775� 4-, `ff7"h�9 !T� <br /> Igc7L_�5 15As cIIHr� <br /> -12 CUP o?24 0 4 ddl <br /> Ln C <br /> C) <br /> l A- <br /> F- G 'K_ Inv, i <br /> tR)01? L j r, <br /> ENVIRONMENTAL HEALTH DIVISION FIDS �- <br /> UNDERGROUND TANK QUST)CLEANUP Gnl1 (LOP} ❑ t10U51K0 A6A'ri+puEKT 0 SOLID WASTE FACiLtrY <br /> 79 OTHER CLEANUP 3,I11k(NON-LCO) 0 FOOD FACIUTY ❑ SOUD WASTE WNICLE <br /> �i UNDERGR0lMn TANK(M0NITC*INQ0teNOVAL) W wG KENNEL M DAIRY <br /> HAYAROOUB WASTE 09NE RA'tOR O CHICKEN RANCH [] PKG IREATMENT PLANY <br /> ❑ T"rD PEMInTED FACawr7 C1 slOTEU1H61T1. 0 1►UYPER TRUGKIYARMHH6nx Tg"TS <br /> Cf TATTOOIRGOY PtrKOwe © POOuSPA CI LAND USE ARPtjCAjVN SHIES <br /> ❑ ldMCAL.WASTE FACILITY ❑ pt m c WATF.9Sywum Q OTHER(PLEAaL SPLOFYABOVE) <br /> t. List up to ten nddrerse3 in the space abavv. Select the typan(s)of files from the Not above by chackirtg <br /> trio appropdatc box(aat), At least ono'hia typo MUST be 691eCted. Fax toto il to thea <br /> ad ftl3l intlkated gMyg <br /> 2. E"D will notify the'applicant If wiy EHO fibs*zIxt. An apgointmerit for review will be Confirmed <br /> approximately five business days but no later than teen(10)Oaya#Aer receipt of application. 'Cite Titer <br /> will be hold for a maximurn of five business dxya far mvivw. Appointments should be scbvduled <br /> ac 0ordiingly. <br /> 3. A file that is actively being WOM90 on by EHD staff may not be immediately available,For mviarw. A now <br /> appllca0on tray be subrr hftd wtton the Hie'IS available. <br /> 4. Ary tine not returned in the'saMe Condition at roloased wilt be,raprganized by EHIi staff at the expense <br /> Of tht agPlicant. Future file rsviews by the aanM6 applicant may require a$79.00 deposit pafor to roview. <br /> 3. `TENTATIVE appoint7sient.dame;must be confirmed with EHO e'twM <br /> 6" APPlicationa eeceivod after 3;00 Pm will be processed the PW b4 girta$$day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX lkrrW'$ _--- <br /> REVIEWED YES NO REVIEW DATE <br /> 00 11 bxkww <br /> TOTAL P.02 <br />