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EMM LOG NUMEEP <br /> SAN ,TOA.QuIN C-o'UN` Y " <br /> MMMVE� 3 <br /> �1vv��.orm�l�ivT'Az! ]H[���a=z D��AR�M��r <br /> 304 E Weber Ave 3" Floor Stockton, CA 95205 <br /> MAR 3 2006 <br /> (209) 468-3420 �'ax: (209) 4d4-0138 �Veb:"vtrww.co.saia-jaaquin.ca.uslehd <br /> ENMROi'dI'VIENT HEALTH <br /> PERMITISERVICES PUBLIC �ca�3s R]Ez��.A sE APPLICATION _ <br /> APPLICANT: a- (C SUSIN7=55fRI5$NGY: - <br /> ADURE5S: <br /> PRONE: FACSIMILE: <br /> T�NTATiVE"APp01fa'rNlENT <br /> � + Time:. <br /> (Please allow 1a business days from date of appiiaation submittal) <br /> CHr=CK BOX TO EXPEDITE RF-QUTST 53.40FEE-FtEgUFST PRQCE$5E0 IN 3 BUSINESS DAYS �+ <br /> C� DATE s.J <br /> SIGNATURE.OF APPLICANT Department Use Ornfy <br /> UNIT <br /> FILE ADORl S$• <br /> �� err } ❑ Unit 1 <br /> s. sweet A,•,,, <br /> .�_ <br /> z. slreal ' <br /> IACIA <br /> cu r ❑ Unit 2 <br /> to I N Cl, I. j <br /> 5. Slrml <br /> at /'W', Unit 3 �I <br /> atr <br /> E. SIreel <br /> 7. Slrcel Cil �V <br /> B, <br /> .. GS ' <br /> 51ee9t <br /> cl _ ❑ Unit 5 <br /> 9, Street - <br /> Ct <br /> 10. s lmq <br /> -ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> fl SOLID YYASTE FAc1rY <br /> Ca' UNDF-FOROUND TANK(US l)CLEANUP SITE(LOP) ❑" HOUSING=ABATFACILITY <br /> >=NT d SOLIDWASTE VFHIGLF. <br /> OTtIER CLEANUP s1-rF-(NON-LOP) 13 FOG FA 11491- <br /> 1 UNDERGROUND TANK(MONrrORINUMEMQVAt� ❑ COG KENNEL l7 DAIRY <br /> 0 CHICKEN RANCH © PI4G TfiEATMENT PLANT <br /> A ARDOUS WASTE GENERATQFt p MQTELIHOTEI, ❑ PUMPER TRUCKIyARDICHEM TOILETS <br /> TIESE-D PERMITTED FACILITY ❑ POOLISPA M LAND UsE APPLICATION SITES <br /> 0 TATTOOI1300Y PIERCING C❑ OTHER(PLEASE SPEC1m. <br /> ❑ MEDICAL WASTE FACILITY <br /> 4 <br /> 1. List up to ten addresses in the space above. Select the type($) of files from the list'abave by checking <br /> the appropriate box(es). At least one file type MUST.be "e selected. Fax to ;i09 464.0138 or mail to the <br /> address indicated above. <br /> 2. EH0 will notify the applicant if any 1=HD 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 business days for revlew. Appointments should be scheduled <br /> accordingly. <br /> 3,. •A file that is actively"being worked on by EHl7 staff May not be immediately available for review. Anew <br /> application may be submitted when the file is ava(l; fble. <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 salTle applicant may require a $93.00 depasi#prior to review. <br /> g. . <br /> *TENTATIVE;appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next bltSlness day. <br /> CONFIRMED APP'OINTME'NT DATE TIM"E <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REV]EW DATE _ <br /> EMP A9.02 00n <br /> Of IMI <br />