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01/14/2005 09:46 FAX 209 6480621 002/002 <br /> E RECEIVED <br /> (�(� SA V OAQ 1_u COUNTY <br /> 11 <br /> wv r, •., tii <br /> ' � W E COVEDD EN-moNmEnAL RxA.LTia DF.PkRTlYIEiY'Z <br /> 304 F Weber Ave 3`d Floor Stockton, CA 95205 <br /> `1 1 OPRP 468-34 0 Fax: (209)464-0138 Web: tiwvtiv.co.San-joaq a4i ca.us/elid <br /> ENVIRONMENT HEALTH p'-gLIC RECORDS UEEME APPLICATION <br /> APPLICANT':_ h rL -- ��, hl <br /> BU$INESS(AGENCY: <br /> ADDPX5S: 'a a 5 - nkw-1, read -tt,� <br /> PHONE: - r3lI FACSIMILE: <br /> TENTATPj'E• POINTMENT DATE: �I o IO� Time: Q 00 <br /> -Tr <br /> (Pisase allow 10 husiness days from data of application submitd) <br /> CHECK BOX TO EXPEDITE REQUEST-$93,00 FEE,REQUEST PROCESSED IN 3 BU$INVSS DAYS (sr <br /> SIGNATURE OF APPLICANT <br /> ' DATE I a I <br /> decartment Use Only ,--. <br /> \V FILE ADDRESS UNIT <br /> �,r <br /> �. shec4 A a 5 <br /> i srr---i l wlilt" ❑ Unit 1 <br /> e Ll * c <br /> r 4 b 0AVI <br /> Unit 2 <br /> \ (moo city ,,tc_ <br /> Av e- 1, L3 it <br /> D <br /> Unit 3 <br /> s. sea t� me'll.fJINO ve a <br /> 7- sreet J21.7 „ City <br /> U04e. sum <br /> ' ❑Cky <br /> su--t FEB Unit 5Ul <br /> to. see I <br /> City <br /> -ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT UL SOLID WASTE FACILITY <br /> OTHER CLEANUP SUM(NON-LOP) in F000 FACILITY ❑ SOL-10 WASTE VEHICLE <br /> 11 UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG K1=1'INCL 129-DAIRY <br /> -' HAZARDOUS WASTE GENERATOR ❑ CHIGXEN RANCH I2-PKG TREATmENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL HOTEL ❑ PUMPER TRUCKlYAADICHI_ht TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOUSPA l& LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) , <br /> 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking <br /> the appropriate box(e�). At least one file type MUST he selected. Fax to (209)464-0138 or mail to the <br /> addressindicated above. <br /> 2. <br /> b ve- <br /> 2. EHb will notify the ap licant if any EHD files exist_ An appointment for review will be confirmed <br /> approximately five bu iness 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 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 new <br /> application may be sujbmitted 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 applicant may require a $93.00 deposit prior to review <br /> 6. "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 /> C4NF�RMID APROINTMNT' a- w <br /> 'DATE CpNFIRMEI) PHONE'. FAX'' x'=;' NfT1f1LS -=r� <br /> REV <br /> IEYVEp '- <br /> YES ._ <br /> 'r REVIE'�Y DATE-.' <br /> EHO 48-a2-aas - <br />