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SAN JOA IIN COUNTYPUBLIC HEALTH SERVI' -.5 <br /> Ehw4RONMENTAL HEALTH DIVISION a <br /> 394 FAST WEBER AVENUE,THIRD FLOOR �J <br /> $TOCKfON CA 95202 <br /> (269) 4683420 <br /> ADDRE'`�aCQS,4 <br /> -P—`j—BLIC RECORDS RELF-A <br /> SE APPLICATION <br /> APLICAtBi5rNE55lAGENCY <br /> 1 <br /> PHONE L)15• 1 -I5 7D�f ... FACSIMV i <br /> TENTATIVE'APPOIhiMENroATE I v ,& Jo, <br /> tlFBMC y{ye T Lp 1e Dusb+�OarF from dam of ayPLk�Len sut+�nal) �'� - ?��r'�--;; <br /> C3 CHECK BOX TO EXPEDITE REC211EST-58r.ee FEE- PROCESSED IN aUSIKES4 DAYS �— - ---- <br /> SIGNATURE OF APPLICANT <br /> 1 FTUE 40ORES5 11 I THIS SIDE END STAFF USE ORLY <br /> Srk'GS ��-. C\SL t1Y L PROGRAM ELEMENTS SEARCH <br /> Nr O Nerih Srrr r4 en n <br /> Wr Sp �ur•ra <br /> N F 10 4>n Sacrarre:n{=o <br /> �.N. • 61 -. a r. .L. <br /> Tdr- 0 ra <br /> Clot S I" <br /> L029 $ Sa r... P . •� <br /> 121 Svu k 54 Crrw mF fA+r • • <br /> ENVE120NMENTAL 1fEALiTi DIVISION FILES <br /> J UNDERGROUND TANK(UST)CLEANUP SITE(LOP) Q HOUSING ABATEMENT CI SOUP WASTE FAO=UTY <br /> OTHER CLEANUP SFM(HON-LOQ) In FOOD FACIUTY CI SOLID W SrC VEHICLE <br /> UNDERGROUND TAW(MONITOAMGMEAWVAL.) Q DOG KERNEL O DAIRY O <br /> HAZAfmOu8✓OWFt:13ENERAT41t O CHICKEN AANCN tI PKG TREATMENT PLANT <br /> ❑ TIERED PE_RMMED FACILITY ' 0 MOTEWHOTEL ❑ PUMET � <br /> PERTRUCWYAR=HUNToiLS <br /> TATTOOIDODY PE1RC1NG ' ❑ PODUSPA 0 LAID USE APPLK:Anox taTts <br /> O MEDICAL WASTE FACILITY K PUHLIG WATER SYSTEM O OTHER(PLEASE SPECIFT AWNE) <br /> i. List up to ten addresses in the space above, SeWA the typo(s)of files from the list above by Checking t ,` <br /> the appropriate boxes). At least one file type MUST be selected Fax to 1=46"138 or mail to theastdresW <br /> EhD will <br /> jnotifyteo.th above. <br /> 2 EHd wI8 notify theapplicant if any EHD tiles 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 files <br /> will Ir6 held for a muWmum of five bustneas days for review. Appointments Should be scheduled <br /> accartfingly. <br /> 3. A file that is actively,being worked on by EHD staff may not be immediately available for review_ A new <br /> appi)cat)on may be submitted When the file is availabie. <br /> 4. Any file,not returned in the sante condition as releaoad will be feorganw-ed by EHD Staff at the expense <br /> of the applicant Future tile reviews by The game apprkGant may require a $07.00 deposit prior to review. <br /> 5. "TENTATIVE appointment dates must be cordiiTmad with EKI)staff. <br /> 6. Appl:cations,received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> "DATE CONFIRMED PHONE FAX tmT(ALS <br /> REViEWED YES NO REVIEW DATE _ <br /> mmu Qc <br /> TOTFL P.01 <br /> TOTAL F.01 <br />