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0002 �l <br /> CIIV LVV 1\Vlvlbl- <br /> 10'28/2004 13:24 FAX 209 9480( <br /> UATLIRECEIvED SAN JOAQUIN CONY <br /> ENVZMONI MENTAL HEALTH))nPART E 'T <br /> 304 E Weber Ave 3 Fl uin.ca.uslehd <br /> (209) 469-3420*'ax: (209) 464-0139 Web:www.co.san jo aq <br /> PUBLIC RECO"S MLEA.SE AXPLXCATION <br /> APPIJCANT_ l Y4- <br /> BUSINESS/AGENCY: <br /> ADDRESS: <br /> C R _Int FACSIMILE: `o <br /> PHONE: <br /> rime: <br /> TENTATW APPOINTMENT DATE: <br /> (please allow 10 business days from data of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-Saa.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS 1 a( <br /> _ DATE <br /> SIGNATURE OF APPLICANT Depart"entUse Only <br /> U NIT <br /> FILE ADDRESS E3 <br /> �r rtr Unit 1 <br /> b uaS�n t 0 r <br /> 2. s 31 ►) N '` G k . J ,F1 , ,,Unit 2, y <br /> Act ti, <br /> U4 Unita 1� . <br /> 6. sued uoo G ;J, Unit 4 <br /> E o - <br /> suedt t ' Unit 5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> [I HOUSING ABATEMENT pgSOL to WASTE FACILITY <br /> p9 UNDERGROUND TANK([1ST)CLEANUP SITE(L.OP) ❑ FOOD FACILITY ❑ SOUD WASTE V>~H1C11 <br /> n OTHER CLEANUP SM(NON-LOP) d DOG}FENNEL DAIRY <br /> JA Ut4DERGROUND TANK(MONITOR1NGlREMOYAL) ❑ Ct11CIC>:N RANCLI ii PKG'TREATMENT PLANT <br /> Ig HA2�RDOUS WASTE GENERATOR ❑ WICKCMQTF_LAN R NL Q PUMPER TRUCKIYPRAICHEM TOILETS <br /> ❑ n'RED pERmlTTED FACILITY [3POOL(SPA LAND USE APPLICATION SITES <br /> ❑ TAT70OSODY PIERCING ❑ OTHER(PLEASE SP£C'M <br /> D MEDICAL WASTE FACILITY checking <br /> to ten addresses in the space above. Select the tYPe(s) of files from the list above by <br /> 1. List up a MUST be selected. Fax to 209 464-0138 or mail to the <br /> the appropriate box(es). At least One file type <br /> address indicated above. ointment for review will be confirmed <br /> 2, EMD will notify the applicant if any EHD files exist An app <br /> approximately five business days but nro later tha <br /> da s n tereviow� Appointmenafter ts should files <br /> be scheduled <br /> will be held for a maximum of five buss Y <br /> accordingly. EHD staff may not be immediately available for review. A neK <br /> 3, A file that is actively being worked on by <br /> application may be submitted when the file Is available. <br /> the same applicant may require a$93.00 deposit prior to review <br /> q. Any file not returned in the same condition by <br /> as released will be reorganized by EHD sta#f at the expens <br /> of the applicant- Future filo review y <br /> 5 *TENTATIVE appointment dates must be confirmed with END Staff. <br /> g Applications received after 3:00 pm will be processed the next business day. <br /> =,GONF:I,R. MSD A OINTMENT-PATS :; �x, <br /> !'PHONE <br /> :DAT>r CONF.IRNIED <br /> .` YES NO REVIEW DATE: <br /> p,EV1EWED <br /> �+o,a-uZ.aoc <br /> arcrzoa i <br />