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11/28/2005 10:28 FAX la 002/002 <br /> DATE RECFJNEO <br /> SAN J�OAQUIN COUNTY <br /> "E U �� I I�i <br /> (D �FIFE-; FNviRONmNTAL HEALTH DEPARTMENT <br /> NOVBGG 304(Weber Ave 3rd Floor Stock ;tonCA 95205 <br /> 209 468-3420 Fax: 209 464-0138 Web:Www.co.sarxjoag=.ca.uslehd <br /> ENVIRON VIENT HEALTH zi 043 <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APFLICAMN <br /> APPL.1CANT; Q 11.,IQ BUSiNE55lAGENGY: KLCtl&I�' h <br /> ti <br /> ADDRESS: <br /> PHONE: ,fig—9•%f 13`15" FACSIMM' <br /> TENTATW APPOWNIENTDATE: !Z! 17 , er tO ae .G ;ess.bto �l <br /> Titne- <br /> (Please allow 1e b%csIrA S days from dale of applicaden subaima8 <br /> l•-� CHECK BOX TO EXPEDITE REQUEST-$33-00 FEF.-R=UeST PROCESSED IN 3 BUSINESS BAYS <br /> SIGNATURE OF APPLICANT lJr DATE I1 �OJ� <br /> DepaAmer t Use Only <br /> F11.E ADDRESS UNrr � <br /> ,. area 5 U - ap unit 17 <br /> z >: 3 /� <br /> - -/Unil2 1 <br /> .. Me" <br /> My Unit 3 <br /> t wed <br /> sub. Unit 4 <br /> L <br /> CJUnit s <br /> -ENVIRONMENTAL f-IEALTH DEPARTMENT FILES <br /> UNDERGROUND TAMC(UST)CLEANUP SITE(LOF*) O HOUSING ABATEMENT BS..SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) O FOOD FACILITY O SOLID wA,S}g VEHICLE <br /> 1p UNDERGROUND TANK(MONrTORiNG1REMOVAL) 0 DOG KENNEL 16L DAIRY <br /> Z HAZARMUS WASTE GENERATOR 13 CHICKEN RAHCt1 E4-PICG TREATMENT PLANT <br /> ❑ TIERED PERAATfTED i=AGtLRY O MOTELMOTEL ❑ PUTAPER'TRUCKJYAR=HEA1 TOILETS <br /> C3TATTOOl90QY PIERCING CI POOLfSPA >a LAND USE APPLICATION STIES <br /> ❑ MEDICAL WASTE FAC1LfiY O 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(es). At least one file type MUST be selected. Fax to 209 46.4-01:18 or mail to the <br /> address.indicated above. <br /> Z- EHD will notify the applicant if any EHfiles exist- An appointment for review will be confirThe med <br /> approximately Five business days but no tater than tan (10) days f les <br /> ointments should be scheduled <br /> will be held for a maximum Of five business days for review. App <br /> accordingly. ely being worked on by EHD staff may not be immediately available for review. A new <br /> 3. A rite that is activ <br /> application may be submitted when the file is available. -at the <br /> a. Any file not returned in the sameecondition e same appl cant may require.a $93.00ed by Hdeposf prior to r v'►ew. <br /> of the applicant. Future file reviews Y <br /> appointment dates must 136 r <br /> 5" �E�caatio s received ate 3 00 pm w l be poces se-Onned th he next business day. <br /> FREVIEWED <br /> IF'bINTM ATE HONE .�:•'r?�:p FAX".�ED• -: .. . <br /> YES NO REVIEW DATE' <br />