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4.3 V;JV cjjVJ.MU41'r-rvIHt- Mt M PA(_L 01 <br /> �Vvc-ty <br /> AN JOAQUIN COUNTYPUBL'IC HEALTH SERVIOSP, <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I'd. "I i, 304 EAST WEBER AVENUE,THIRD FLOOR 997 <br /> STOCKTON CA 95202 <br /> r'!j 10: U13LIC RECORDS9REL3420 <br /> EASE APPLICATION <br /> APPLICANT MaLy) BUSINESSIAGENCY_ � �'I <br /> AbDRESStI IQ3t/ k�a 34 <br /> `f <br /> PHONE FACSIMILE 5 �- ~i J4-�a <br /> Q <br /> TENTATIVE`APPOINTMENT DATE ' `'�-)AT TIME <br /> (Please glue to 0 business from dit F�ppll tion submittal) <br /> � I � <br /> CHECK 80X TO F.XpEDrrE RE E T-=89. 0 REQUEST PROCE 3 SINESS DAYS <br /> -SIGNATURE OF APPLICANT DATE b I g D� <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> t <br /> Show RA. 5 <br /> 20 <br /> �� ENVIRONMENTAL HEALTH DIVISION FILES <br /> ;K UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> O OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY Q SOLID WASTE VEHICLE <br /> ❑ YNDERGROUND TANK(MONITORING/REMOVAL) O DOG KENNEL 0 DAIRY <br /> IAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH C3 PKG TREATMENT PLANT <br /> 0 TIERED PERMITTED FACILITY d MOTELJHOTEL ' O PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOIBDDY PEIRCING O POOLISPA 0 LAND USE APPLICATION SITES <br /> M MEDICAL WASTE FACILITY O PUBLIC WATER SYSTV_M D OTHER(PLEASE SPECIFY ABOVE) <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(es). At least one file type MUST be selected. Fax to (209)464-0138 or mail to the <br /> address indicated above. <br /> Z 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 (1a) 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 aptively being worked on by EHD staff may 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 t:ondlt)on 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$89.00 deposit prior to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> s. 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 /> X"49n 2U b2:OT Z00Z eT Nnf <br /> Z01Z0'd 8ET0b9b60ZT 01 <br />