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SAN JC JUIN COUNTYPUBLIC HEALTH SF 'ICES / <br /> ENVIRONMENTAL HEALTH DIViSIOi- t <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> $ipt✓pCTON CAIC�"`cJ <br /> (209)468-342020 <br /> 1 E APPLICATION <br /> PUBLIC RECORDS RELEASE _-- <br /> Fi . . f <br /> BUSINE"asIAGENCY <br /> ¢PPLICAN <br /> ADDRESS Lel #7- / <br /> PHONE >ACSIMILE / <br /> TIME <br /> TENTATIVb=*APPOINTMCNT DATE <br /> {Please give 7 to 10 busiOns clays from data of application submittal} <br /> CHECK BOX Ta EXPEDITE REQUE - 78-01)FEE•-R[ £ PF20C SSED W 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT <br /> FjL.0 ADDRESS <br /> U� <br /> ri <br /> Q caw <br /> -- srT mrd.AB SiT+ti O Oso <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> CI SOLID WASTr=FACILITY <br /> HOUSING <br /> UNDERGROUND TANK(UST)CLEANUP SITE(I-OF) ❑❑ FOOD FAG1 TMf=HENT 11 SOLIU ti^lASTE VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) C DQG KENNEL q DAIRY <br /> UNDERGROUND YANK(MONITORINGIREMOVAL) CI GIfICKr=N RANCH 0 PKG TREATMENT PLANT <br /> HAZARDOUS WASTE=GENERATOR ❑ moTEL/HOTEL L7 PUMPER TRUCKfYARDICHEM TOR-CM <br /> TIERED PERMITTED FACILITY ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOISORY pEiRCING E3 PUBLIC WATER 5YSTEM d OTHER(PLEASE SPECIFY ABOVE) <br /> In MEDICAL WASTE.FACILITY <br /> 1. list up to ten addresses in the space above. Saiect the type(s) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to 2Q9)464-0138 or mail to the <br /> addre$s indicated al_ove. <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 butgness days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A file that is actively being worked an by EHD staff anaiy 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 same condition ac released will be reorganized by EHD staff at the expense <br /> of the applicant Future file reviews by the same applicant may require a $78,00 deposit prior to review. <br /> g, "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 /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> en vv i+ ot�oNda <br />