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LHD LCJG NUMOf f" <br /> DATF,RECEIVEU SAN JOAQUIN COUNTY • <br /> FPivjR0 NM.ENTAL HEALTH DFPA-RTI F,N'T <br /> 304 E Weber Ave 3"3 Floor Stockton, CA 95205 <br /> Z35?3 <br /> (209)468-3420 Fax: (209) 464-01.38 Web: vwww.co.sa. joaquin.ca.usfelZd <br /> pUBLTCRECOpjDS RELEASE APPLICATION <br /> U� <br /> Ir � baa�S ` BU5INFSSIAGENCY: <br /> APPLICANT:G� �_ �._ <br /> ADDRESS: 1 �} r� <br /> FACSIMILl=: D1,1 ✓ <br /> PHON1=: <br /> TENTATIVE"App01NTMENT DATE: lime: �---- <br /> (please allow 10 business days from date of application submittal} <br /> 'HECK BOX TO EXPEDITE R UE T-S93.00 F —REQUEST PROCESSED IN 3 BUSINESS DAYS � �� <br /> —�� BATE <br /> SECN�ITURE OF APPLICANT De� P'ZC-Int Use Only <br /> 'X <br /> FILE ADDRESS <br /> ] 111 Gl:v C'C , <br /> CII <br /> z. & cel u Unit 2 <br /> •y �, I7 <br /> 8. Slre01 J •r'v <br /> Gi I '1 <br /> 4. Sine" � a: ( z p� Unit 3 <br /> J <br /> 5. Vrea, <br /> G <br /> E. Slreal � Unit 4 <br /> Gr <br /> T. &MQ1 <br /> G! <br /> E. SITIM Unit 5 <br /> Ir 'F <br /> 9. Suael - <br /> 1Q. Sirrc! <br /> ENVIRONM TMENT PILES <br /> ❑ J GUSING ABATEMENT 13 SOLID WASTE FACILITY <br /> UNDERGROUND TANK(UST}CLl"ANUP-SITE(LOP) 0FOOD FACILITY Cl SOLA?WASTE VEHICLE <br /> OTHER CLEANVP SITE(NOWLOP) Q DAIRY <br /> hz UNDERGROUND TANK(MONIToRING1RFMOVAL) © DOG KENNEL ❑ PKG TREATMENT PLANT <br /> HAZARDOUS WASTI�GENERATOR O CHICKEN RANCH <br /> ` 0 11ry07I:LlHOTEL d PUMPER7fiUGKIYAtidICF{l=F�TOILETS <br /> Z, TIERED PERMITTED FACILITY p POOUSPA ❑ LAND USF-APPLICATION SITES <br /> d TATT00,1310DY PIERGING ❑ OTHER(PLEASE SPECIFY) <br /> p M>"DICAf.Yb`ASTE FACILITY <br /> e list <br /> 9. List up to ten addresses in#Ieaspone filetypetype MUST ove. Select the ehe lected f FlaXatoo?_09h464-013$vorbm�i!vcthleg <br /> tha appropriate box(es). A <br /> address indicated above. <br /> EHD will notify tate applicant if any EHD files exist. An appointment for review will be confirMe <br /> approximately five business days but no later than ten (10) dayser rerl6 spt hould of li sc1 ed The files <br /> will be held for a maximum of five business days for review. Appointments <br /> led <br /> accordingly. <br /> 3. A file that is actively being worXed on by EHD staff may not be immediately available far review. never <br /> application may be submitted when the file is available. <br /> 4, Any file not returned in the same conwill be reorganized by EHD staff at toe expense <br /> condition as released eposit prior to review, <br /> of the applicant. Future file reviews by the same applicant may require a$93.00 d <br /> 5. "TEtATATIVE 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 1NITIAL•S <br /> REVIEWED YES NO REVIEW DATE <br /> Er�p aaaz-aos <br /> sxu2naa <br />