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07/08/2002 MON 12,50 FAX 916 5654356 8001/001 <br /> U,/U."nuL to:vB abaU ENVIRONMENTAL TH PAGE M <br /> SA�JOAQUIN COUNTYPUBLIC HEALTH SE <br /> , RVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUETHIRD FLOOR i <br /> STOCKTON -3420 CA 95202(20 <br /> PUI�BLIC RECORDS9) <br /> APPLICATION <br /> APPLICANT ' rjea.e/l �5 <br /> RUSINESSlAGENCY <br /> ADDRESS <br /> PHONE <br /> _ '�'-"s�•`�-- KACSIMILE <br /> Q-TENTATIVE'APPoINTMCNT DATE <br /> f`._, im" <br /> TIME <br /> �,CHECK BOX TO EXPEDITE RE1NES$PAYS <br /> SIGNkl,'URE OF APPLICANTG ❑ATE at. .. <br /> FIt.E ADDRESS THIS SIDE EHD STAFF USE!ONLY <br /> PROGRAM ELEMENTS SEARDH O <br /> v J 9'57- <br /> 114 <br /> r <br /> z <br /> \j <br /> .ar ,J � � 5 <br /> tiV <br /> z�• <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> Of UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 17 HOUSING ABATEMENT <br /> 11O SOLID WASTE LITOTHER CLEANUP SITE(NON-LOp) Y <br /> O FOOD FACILRY ❑ SOLID WASTE VEHFACILITY ICLE <br /> LIT <br /> ❑ UNDERGROUND TANK(MONITORING/REMOVAI) ❑ DOCKENNEL ❑ DAIRY <br /> 10 HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PL/NET <br /> ❑ TIEREO PERMITTED FACILITY O MOTELMOTEL E] PUMPER TRUCWYAROICHEM TotLETS <br /> ❑ TATYOOIDODY PEIRCING ❑ FOOLISPA CT LAND USE APPLICATION Sr= <br /> ❑ MEDICAL WASTE FACTL , ❑ PUBLIC WATER SYSTEM o OTHER(PLEASE SPECIFY ABOVE) <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 mall to the <br /> address indicated above - <br /> Z- E.HD 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 ton(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 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 condition as released will be reorganized by EHD staff at the expense <br /> Of the applicant Future file reviews by the some applicant may require a $89,00 deposit prior to review, <br /> 5. 'TENTATIVE appointment dates must be Confirmed with EHD staff. <br /> .6. 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 /> RevIEwCD YES NO <br /> REVIEW D <br /> A ATZ_.. ..— <br /> "1!•VI <br /> Post-H•Fax Note 7671 °q�7 rt. a� ► <br /> To • From • <br /> A <br /> CelDept o. "'–GD E' <br /> Pnona It hw�e•LCl G 5'- Zd <br /> F - 7.0 -1 <br />