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I <br />IVA <br />- 4'ab-19• 2002 2:bORM OR EARTH IECHNOLOGItS 'io•b4Ui <br />DATA RECEIVED 0 <br />-0 END Loa&X16 <br />SAN JOAQUIN COUNTYPUBL,IC HEALTH SERVICES 01 41P <br />77* ENVIRC)NMENTAL. HEALTH DIVISION 7 <br />304 EAST WEBER AVENUE, THIRD FLO r,.��� <br />$-WF OCKTON. <br />(209) hOPLICATION <br />USLIC RECORDS FELE - <br />APF CANT ��-v i kko 4 �,��1. 5 BUSINESSIAGENCY Cov ctor �.r � Qc 1tiYt 0 L0 l aS �.ZC• <br />ADDRESS + C_ c -1,Q <br />PHONE 2-0-1 - 23 - C>S18 FACSIMILE 2Q`fi z 3 5'd� <br />TENTATIVE} APPomTmEur DATE TUNE <br />(Please give 7 to 1 business days from date o application sub ittal) <br />CH!~C}( BOX TO EXPEDITE RI"QUEST - $87.pp l` - W <br />T PRO <br />>lS Aeso, <br />SIGNATURE OF APPLICANT DATE Z I6'j 00 z... <br />FILE ADDRESS THIS SIDE EHD STAFF USE ONLY � <br />PROGRAM ELEMENTS SEARCH <br />A4 3 5 . A� Y -D a -r -t o NI - <br />I S S o vt cai,tti i A l r. <br />52.5 l•� <br />f O I t7 c2. <br />/41 <br />3 (0 2.. /as : tr v t <br />ENVIRONMENTAL HEALTH DN'ISION FILES <br />ZL73NDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT OLID WASTE FACILITY <br />� nTHER CLEANUP SITE (NON -LOP) © FOOD FACILITY ❑SOLID WASTE vEHICL.E <br />d UNDERGROUND TANK (MONITORING/REMOVAL) ❑DOG KENNEL �' OAIRY <br />c%AZARDOUS WASTE GENERATOR CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACII.JTY 0 MOTEI..IHOTEL O PUMPER TRUCK(YARD/CHEM TOILET'S <br />❑ TATTOO/BODY PEIRCJNG ❑ POOL/SPA • , Q LAND USE APPLICATION SITES <br />M MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ 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 (W09) 464-0138 or mail to the <br />address indicatrd above. <br />2. EHD will notify the applicant if any EHD files exist. An appointment for review will be ccnfrmed <br />approximately five business 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 bging 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 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 />6. Applicatlons received after 3.00 pm will be processed the next business day, <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />