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07/13/2005 09:06 209-579-2225 MODESTO ATC PAGE 02 <br /> DATE RECEIVEDEHCI LOG NUM81 <br /> RDECENED SAN.T/)E#QIJIN COUNTY <br /> B'NvmONm ENT.,►L B EAtLTH DEPARTMENT <br /> 304 E'Weber Ave 3nd Floor Stockton, CA 95205 <br /> JUL r 3 M 468-3420 Fax: (209)464-0138 Web:www.co.San joaquin.ca.uS/ehd 7 <br /> EN�IRQNMENT HEALTH PUBLIC RECORDS RIMEASE A,PPLICA110N "D a^� <br /> PERMI 1/t�hLlUtO <br /> rrr� _�snen�e <br /> APPLICAN CA 0 BU 11 ESSfADENCY: r L \ C� <br /> ADDRESS: 1 L Pa F ) <br /> PHONE 1 q - 2 � I FACS MILE: 14 - ZZZ <br /> TENTATIVE"APPOINTMENT DATE:—-,-) - Z G' O S-- Tlme: t ' <br /> (Plea"allow 10 business i days Irom date of appliestlon aubmlttal) <br /> CHECK BOX TO EXPEDITE.REQUEST-$93.00 FEE-REC UEST °ROCESSED IN 3 BUSINESS DAYS <br /> I <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> sfr..cs ❑ Unit 1 <br /> x avees <br /> 4. sty ❑ Unit 2 <br /> a , a Unit 3 <br /> 7. Stremt <br /> e, « Unit 4 <br /> opt <br /> ,o stmt C ❑ Unit 5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> Fd' UNDERGROUND TANK(UST)CLEANUP SITE(LOP) C7 HO JSINO ABATEMENT C7 SOLID WASTE FACILITY <br /> tlQTHER CLEANUP SITE(NON-LOP) 0 FO)D FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGMEMOVAL) ❑ DO a KLAN IEL G DAIRY <br /> e'HAZARDOUS WASTE GENERATOR ❑ CH CKEN RANCH ❑ PKQ TREATMENT PLANT <br /> 0-nr-RI:D PERMITTED FACILITY ❑ MO rEL1HIlTEL ❑ PUMPER TRUCK/YARDICHEM TOMM <br /> ❑ TATTOOtBODY PIERCING ❑ PO XISPIt ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTI IE-:R(P LEASE SPECIFY) <br /> 1. List up to ten addressas in the space abo to. S elect the type(s)of files from the list aboys by checking <br /> the appropriate box(es). At least one file 1 ype MUST be selected. Fax to (209)484-0138 or mall t9 th2 <br /> address indi!Rgt above. <br /> 2. EHD will notify the applicant if any EHD fil as exist. An appointment for review will be confirmed <br /> approximately five business days but no I Oer t ian ten (10)days after receipt of application. The flies <br /> will be held for a maximum of five busine::s days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A five that Is actively being worked on by I NO staff may not be Immediately available for review. A new <br /> application may be submitted when the fii& is a rallable, <br /> 4. Any file not returned in the same COndltloi t as raleased will be reorganized by EHD staff at the expense <br /> of the applicant. Future file reviews by tht 1 same applicant may require a$83.00 deposit prior to review. <br /> +. *TENTATIVE appointment dates must be t onflrnad with EHO staff. <br /> 6. Applications received after 3:00 pm will bc processed the next business day, <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS . <br /> REVIEWED ,_ YES NO REVIEW DATE <br />