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--.---44/19/2005 12:56 FAX 209 94803; - X1002/002 <br /> Fp-)zz757nE SAI.JOAQ'crnv' COUNTY <br /> ENVIlRon ENTAL BEAU,DEF'ARTMINT <br /> SES' 1 9 2005 304 E Weber•Ave 3"1 Floor Stockton;CA 95205 <br /> (209) 468-3420 Fax- (209)464-0138 Web:ww v_co.saa joaquin.ca.us/chd <br /> ENVIFMilENT HEALTH <br /> P`EGR,,1!T/SERVICESl?ITB,LYC "CORDS FELEASE APPLICATION <br /> APPLICANT: rABUS(NESSIAGENCY: <br /> ADDRESS: `1 <br /> PHONE: ZA9^ g g 1 y FACSIMILE �f �La <br /> TENTATIVE"APPOINTMENT DATE In ZaT1rte: <br /> (Please AIWW 10 business days from date of sPPlicadcli submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-V3.00 VEE-REQUEST PROCESSED IN 7 BUSINESS DAYS <br /> DATE ���� <br /> SIGNATURE OF APPLICANT Q�) —_ <br /> Departmentuse 0* <br /> UNIT <br /> FILE ADDRESS <br /> �. sraa I Z7 1 a �' ❑ ' Unit 1 <br /> z s�rca 3 SS H- �• ���� <br /> a sum rJ Unit 2 <br /> Z.� G C T �1 <br /> t. <br /> .. sL Unit 3 <br /> 5. 5+{ed U <br /> G <br /> s. siredF Unit 4 <br /> 7. <br /> trJ. M <br /> "- 51i� � ❑ Unit 5 <br /> 3 W .A <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILE$ <br /> O HOUSING AHAT'cMENT mL.50L1D WASTE FACILrTIf <br /> UNnERGROUND TANK(u57)CLEANUP SrrE(LOP) ❑ FOOD FACLIT13IY SOLID WASTE VEHICLE <br /> OTHER CLEANUP SrrE(NON-LOP) KENNEL Ig-DAIRY <br /> UNDERGROUND TANK(MONITORINGIREMOYAL) ❑E3DDGCHICKEN RANCH �-PKG TREATMENT PLANT <br /> � <br /> Z 06US WASTE GENERATOR ❑ PUMPER TKUCK[YARDICHEM TOILETS <br /> Q TIERED PERiNIiTED FACILny 0 POMOTELA{OTELIHOTEL M LAND USE APPLICATION SITES <br /> ❑ TATTOO/1300Y PIERCING p OTHER(PLEASE;SPECIFY] <br /> n MEDICAL WASTE FACILITY <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 he selected. Fax to 209 464-0138 or mail to the <br /> address,indicated above. y ointment for review will be confirmed <br /> 2. EHD will notify theapplicant if an EHD files exist. An appa 151 <br /> approximately five business days but no later than ten (10) days afterreceiptsofa should siondTh les <br /> will be held for a maximum of fire business days for review- Appointments <br /> accordingly. <br /> ed on by EHD staff may not be immediately available for review. new <br /> 3. A file that is actively being work <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 /> S. -TENTATiV.F appointment dates must be confirmed with EHD Staff. <br /> g, Applications received after 3:00 pm wilt be processed the nextbusiness day. <br /> T, ATE' <br /> =T <br /> ONF�Rh+I�D'Aps?alrr'r,MEty.- :.�.::�;•.1::..•:-, •_ .-,�•"�'• •�"�'= - - ' ' • . <br /> ,. �' - :r,':^i•�' PHONE .I����:..I;.j S ;"i:E��•. <br /> ;1.. - •• D .- FAX' ,•��..,.s��iN1:C1A1:, '�, . <br /> lb,Klt,QNF,iRtYt� -REVIEWED YES NO REVIEW DATE_ <br />