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.Te Receveo �8�(�" (� n� <br />SAN Jt AQUIN COUNTYPUBLIC HEALTHr=RVICES �� u� t�O V �D <br />Aft Un ENVIRONMENTAL HEALTH DIVISION <br />Uff Ilk 304 EAST WEBER AVENUE, THIRD FLOOR NOV 1 2 2002 <br />& STOCKTO 95202 <br />(209) 468-3420 ENVIRONMENT HEALTH <br />PUBLIC RECO 1= APPLICATION p <br />APPLICANT(NESS/AG r"L /''s <br />ADDRESS�y'�, .7iga ; <br />PHONE 3 "l �3`"'� FACSIMILE �� pC' �" <br />TENTATIVE" APPOINTMENT DATE /�7 TIMEl <br />(Please give 7 to 10 business days from date of application submittal) <br />• <br />13 CHECK BOX TO EXPEDITE S - b F+ R/EQ P , N INES AY <br />SIGNATURE OF APPLICANT , --7 DATE <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />,21'UNDFRGROUND TANK (UST) CLEANUP SITE (LOP) <br />Ab OTHER CLEANUP SITE (NON -LOP) <br />UNDERGROUND TANK (MONITORINGIREMOVAL) <br />HAZARDOUS WASTE GENERATOR <br />TIERED PERMnTED FACILITY <br />t] TATTOOIBODY PEIRCING <br />MEDICAL WASTE FACILITY <br />1. List up to ten addresses in the space above. Select the types) 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 />2. 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 (10) days after receipt of application. The tiles <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 />apptication may be submitted 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 $87.00 deposit prior to review. <br />5. *TENTATIVE appointment dates must be confirmed with EHD staff. <br />G. Applications received after 3:00 pm will be processed the next business day. <br />■ <br />■ FOOD FACILITY <br />■ DOG KENNEL <br />■ CHICKEN RANCH <br />■ MOTELIHOTEL <br />f PdOLiSPX <br />❑ PUBLIC WATER SYSTEM <br />OLID WASTE FACILITY <br />SOLID WASTE VEHICLE <br />1' DAIRY <br />0 PKG TREATMENT PLANT <br />0 PUMPER TRUCKIYARDICHEM TOILETS <br />O ' LAND USE APPLICATION SITES <br />O OTHER (PLEASE SPECIFY ABOVE) <br />CONFIRMED APPOINTMENTMATE <br />DATE CONFIRMED PHONE FAX INITIALS <br />�IFWED YES NO REVIEW DAIZ <br />2000 TZ909V6 6OZ XV3 LZ:Vl ZOOZ/TT/TT <br />