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01/12/2005 14:19 FAX 209 9480r f <br /> t I 0 002 <br /> MCKIVE=D <br /> SAM JOAQUIN COUNTy <br /> ENYMONIVIViTAL REAz,T11 REFARTMENT <br /> 304 E Weber Ave 3'O Floor StOcktan, CA 95205 <br /> .1'.N 12 7005 (209)468-3420 IF= (209)464-0138 Web:www.c0-&M-'oa uin <br /> 1 Q .ca,tls/ehd <br /> EWRQNMENT HEALTH PUBLIC RECO"S RELEASE APPLICREAPPLCAN-r. A'TxON' <br /> • <br /> r-aVU �tA BUSNESSiAGENCY: t<r r / <br /> ,j 1\ E i N Tom. <br /> ADOMSS: � �e-- <br /> PHONE: <br /> --PHONE a F <br /> ACSIMI 9 S'-- 4!o OL l lY.. <br /> TENTATIVE*AppbwrrMEHTDATE //P�r fjs iQ1�t <br /> (Please allow Ja business days fivm date of a <br /> FEaratian submittalj_ <br /> CHECK BOX TO EXPEI)fT. PEQUEST-SM.0a Fes--REQjjeV PROCESSED W3 9USMESS DAYS <br /> SIGNATURE OF APPLICANT � , �� <br /> DAT>; <br /> bewwtnem we only <br /> PILE ADDRESS <br /> ,. a71 W2;; UNtT� G <br /> '• Atm 130 W Ki. PIG <br /> 2 V <br /> S. 9„etl11"12 $ Bi woo <br /> i I S unit <br /> PR--cq-37 6 3 s 1VP <br /> (LW) a s� unit 4 <br /> 9. So-eei 'S. <br /> ta, saee, Unit S <br /> •EWRONMENTAL HE•ALTN DEPARTMENT FILES ��• � � <br /> vNOFRGROiJH0 TANK <br /> NST)CI.tJWUP SUE iiOpl D k10USING A$ATEfHF.NT' <br /> OTI9LsOi1D WASTE FACII-PY nYr <br /> HER CLEANUP SITE ❑ FOOD FACiLr1Y p 1 VX <br /> UNDERGROUND TANK(MONITORINGAi JEMOVAL) 0 DOG KENNEL EL DAIRY Y1fA. VEHICLE <br /> AS HAZARDOUS WASTE GENERATOR D CHICKEN RANCH � � -, <br /> la TIERED PERMITTED FACILITY ❑ CHICKEMOTELRANOTEL PKG TREATMENT PLANT <br /> 0 TATTOO1900Y PIERCING A PUMPER TRUCKlYARD1CHFA To <br /> 0 MEDICAL,WASTE FACILITY ❑ POOLISPA M LAND USE APPUCATION sm 1 <br /> ❑ OTHER(PLEASE SPECK <br /> 1• List up to ten addresses in the space above. Select the type(s)of riles from the list aboye by Checking <br /> the appropriate box(es). At least one file type MUST be selected. Eax to 209 46.4-0138 or mail to the <br /> address.Indicated above. <br /> 2- EMO will notify the applicant if any EHD files exist. An appointment for review will be confirmed: <br /> appraxlmately rive business days but no later than ten (10)days after receipt of application. The tiles <br /> will be for a ri aXimurn Of fYe business[lays 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 ney <br /> application may be submitted when the'file is available. <br /> 4• Any file not returned in the same condition as released will.be reorganized by EHD Staff at the expense <br /> of the applicant,' Future file reviews by the same appliprit may require a$93.00 deposit prior to reviey <br /> 5, 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6• Applications received after 3:00 pm will-be processed the next business day. <br /> CONF�R�MiQ,:Ai�arrriyitl� �,w <br /> I)A7E. QfVF`IItI�Ei) ;, _ Mr4'' _ ;r`:s,' ' Ac: •i r' <br /> . • PHONE . FAX <br /> +_ YES NO REVIEW"DATE' <br /> &HO�a-Gi-0Os <br />