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DATE RECEIVED FHD Loc NUM2E_R <br /> 16 <br /> Ill]E h � V E D RONMENTAIAHr-AT°�D PA.127M.T+NT <br /> 304 B Weber. Ave 3r'FIoor Stoe'tctoia, CA 95205 J I <br /> .iU1Ii `) 3 2006(209)465-3420 Fax: (209) 464-0138 Web:www,co.san joaquin.ca.us/eltid q(••/+ 3 <br /> ENVIRONMENT HEALTH PJ41ILXC RECORDS ItELFASE APPLICATION _ <br /> P <br /> APPLICANT:=}' S 1cJ_S SUSINESSiAGENCY: <br /> ADDRESS: _-j --�j,. ( y •T. --- <br /> PHONE: / -3 / 0 FAGSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: � � <br /> lease allow 10 6usin day., om date of application submlttaq <br /> CHECK BOX TO EXPEDITE RE UE T-593.00 FEE UEST P .F SED IN 3 BUSINESS DAYS / <br /> a <br /> SIGNATUiRE OF APPLICANT DATE 1 1171M _ <br /> Uepartrmmt L'se Only <br /> FILEADDRESS — <br /> ji � UNIT <br /> 'r11,` Gr <br /> t. S'rrol W 1�I Glv (, �1� V'r` J <br /> Unit 1 <br /> .(� Cil Unit 2 ^ <br /> 7 Sr• tl� e Gly <br /> 1. Simi 1 G Unit 3. 'n n✓✓VVV <br /> e. ssccl � cityLL/ <br /> T_ SSit"tim. cin � Urtit4 <br /> Street city <br /> ENVIROb I EPARTI,� <br /> !��UNOERGROUNO TANK(UST)CLEANUP SITE(L 1 HOUSING ABATEMENT i❑ SOLID WASTE FACILITY <br /> )R OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY M SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL M DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH 17 PKG TREATMENT PLANT <br /> TIERED-r ERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEN.TOILETS <br /> ❑ TATTOO/'BODY PIERCING ❑ POOLISPA 0 LAND USE APPLICATION SfRES <br /> 0 MEDICAL.WASTE FACILITY ❑ 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 206.1 464-0138 or mail to t(r_ <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 reoeipt of application. 'i be lies <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 same applicant may require a $93.00 deposit prior to rt vipw. <br /> S. "TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business da.y. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> I <br /> REVIEWED YES NO REVIEW DATE <br /> aHC<a.abAO, <br /> OJW:OOb <br />