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MAY. 18. 1004- 2: 08PM `NTGOMERY WATSON NO, 923EHOLP. JUMBER <br /> DATE RECEIVED SAN JOAQUIN COUNTY 'Voo'r <br /> I n [ ��, II��I D ENvIRON MNTA>L H��. DEP9$ SIVT <br /> 304 E Weber Ave 3Ta Floor Stockton, uin•ca.us/ehd <br /> MAY 1 8 2%) 468-•3420 Fax: (209)464-0138 Web:wwW-co.SaA-1 oaq <br /> i,1VilENT HEALTH PUBLIC pEC4R)DS RELEASE APPLICATION <br /> APPIJCANT: cr <br /> rBIJSINESSIAGENCY: <br /> ADDRESS: ` �e�o��©� l <br /> FACSIMILE: <br /> : $g <br /> PHONE �l4-( i <br /> Time: <br /> TENTATIVE"APPOINTMENT DATE: I <br /> (Pleas®allow,10 business days from date of app <br /> Rcation submittal <br /> In CHECK BOX TO EXPEDITE REQUEST-$93 00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> DATE O <br /> SIGNATURE OF APPLICANT4 pepartm nt Use Only <br /> UNIT <br /> FILE ADDRESS <br /> S+oe' o✓1 a ❑ Unit 1 <br /> z s S a <br /> Unit 2 �-(�� <br /> a. s �� � <br /> cAty <br /> C �! <br /> 6. street L_ O v'1 6 Cf, <br /> Unit <br /> ,. sit ('lO o 0 <br /> Ci <br /> 6, stmt Unit 5 <br /> 9. S et <br /> 0. 3lreet <br /> z 1 Gt q <br /> ENVIRONMENTAL HEALTH I)EPARTMEN-'FILES <br /> ❑ HOUSING r3SOUD WASTE FACILITY <br /> $( UNDERGROUND TANK(UNG ABATST)CLEANUP SITE(LOP) p FOOD NG A13 ❑ SOLID WASTE VEHICLE <br /> L3OTHER CLEANUP SITE(NON-LOP) C3' DAIRY <br /> VE UNDERGROUND TANK(MONITORING1RF-MOVAL) Cl DOG KF-1l0 CHICKEN RANCH [3PKG TREATMENT PLANT <br /> JELHAZARDOUS WASTE GENERATOR p MOTELIHOTEL ❑ PUMPER TRUCK/YARDICtiEM TOILETS <br /> a TIERED PERMITTED FACILITY ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br /> 0 TATTootBODY PIERCING ❑ OTHER(PLEASE SPECIF'1� <br /> O MEDICAL WASTE FACILITY <br /> ace above. Select the type(s)of files from the list above by checking <br /> 1. List up to ten addresses in the Sp <br /> MUST be selected. Fax to (209)464-0138 or mai{to the <br /> the appropriate box(es). At least one file type <br /> address indicated abointment for review will be confirmed <br /> 2. EHD will notify theapplicant if any EHD files exist. An appcation. The files <br /> approximately five business days but no later than ten(10)days ointments should after receipt of appli scheduled <br /> will be held for a maximum of five business days for review. App <br /> accordingly. <br /> 3. A file that is actively being worked on by EHU staff may not be immediately available for review- n®� <br /> application may be submitted when the file is available. by EHD staat the <br /> 4- Any file not returned in the same condition as released will <br /> may rereorganized 893 0 deposit prior expense review <br /> of the applicant. Future file reviews by the same applicant <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 /> l� Y °„RP§Ir�TasCA� ,�ti_.r. �, --- �,- L- f1'/� y:, '” <br /> ,. ,� ,y ;>r", 1, r. •w t1; •Y. yob �� <br /> �}Er' 4y4i. ',t, ',:fir' , 1aI�YFL ��•..�,(._�.�►'=— �I <br /> DATE GONIr'y l :,�r �' ,• ,. o s ;,, �� <br /> N,5'' El�f <br /> REV IEWGI� — <br /> EMO 42.02.006 <br /> M/2003 <br />