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iv"28/2004 13:24 FAX 209 941 003 <br /> DATE RECEIVED SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3'Floor Stockton, CA 95205 <br /> (209)469-3420 Fax_ (209)464-0138 Web:www.co.san joaquin.ca us/ehd <br /> -/ <br /> pUBJLIC RECORDS RELEASE APPLICAMN <br /> APPLICANT' <br /> S BUSINESSIAGENCY: 'elf <br /> ADDRESS: a � 2)4- GMa,r+le� -e �tl� l CJS°�aS <br /> PHONE; �I S� M5 FAGSIMlL1:/ g qua�c�ar <br /> TENTATIVE'APPOINTMENT DATE: I J t I6-1 Tim: <br /> (Please allow 10 business days from date of application subm-Rfal) <br /> ❑ CHECK BOX TO E"EDfTE REQUEST-$91.00 FEE—REQUEST PROCESSED W 3 SUSMESS DAYS <br /> SIGNATURE OF APPLICANT _ Yom" _� � DATEr�I�'�i <br /> Department Use Only <br /> UNfr <br /> FILE ADDRESS ` <br /> l.tt ,• s&elm <br /> clW� <br /> Unit'I <br /> i Unt 2 1 <br /> 1 <br /> Unit 3 <br /> +, Shcd �' G <br /> A 1 S• St.cd <br /> 8. Slrcel -1 <br /> `���..._: <br /> [�rUnit 4 <br /> s� j <br /> a. su�ec <br /> Unit 5 <br /> 9. 511Ce1 <br /> Io, Shret <br /> ENVIRONMENTAL HEALTH OF-PARTMENT FILES <br /> AATEMENT .0 SOUO WASTE FACILITY <br /> (Z,UNDERGROUND TANK(UST)CLEANUp SITE(LOP) ❑ FOOD❑ HOUSING NG ABAT El SOLID WASTE VF;WCL.E <br /> IS OTHER CLEANUP SITE(NON-LOP) ❑ DOG KENNEL DAIRY <br /> LITY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH IE PKG TREATMENT PLANT' <br /> X HA7ARDOUS WASTE GENERATOR ❑ CHICKEN <br /> R EL 0 PUMPER TRUCKI`fARDfGHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY ❑ POOL/SPA IL LAND USE APPLICATION Sri ES <br /> ❑ TATTOOMODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> O MEDICAL WASTF-FACMATY <br /> 1. List up to tan addresses In the space above. Select the typ (s)of files from the list above�y checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to 209 46.4-0138 or mail to the <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 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 ac;bvely being worked on by EHD staff may not be immediately available for review. Anew <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 review <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> g. Applications received after 3:00 pm will be prose-ssed the next business day. <br /> t., TIME xy ;,, ;r: <br /> ;COt�f�_9,R1. D A ,E 604TMENt DATE : ,. , <br /> ONFIRMEDpHONE . FAX'' <br /> :DATE <br /> REVIEW DATE.- <br /> RE�fIEWED YE5 NO 1 ` <br /> • Eµn 4a•oz•aas - <br /> nrarzaoz <br />