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NS sHD Lai NUMBER SAN JOAQUIN COul TY 4-, <br /> EN'VIRONMfENiA,U HEALTH DEPARTMENT <br /> NOV 2 o 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> �09)468-3424 Fax: (209) 464-0138 Web: www.co,san-joaquin.ca.us/ehd <br /> ENVIRON ENT HEALTH J q9 <br /> PERMIT/`SERVICES FU)3LIC''RECOR3)S RELEASE APPLICATION <br /> APPLICANT:Q filo 6,V%- E4 _R SUSINZSSIAGENCY: <br /> ADDRESS: q02- <br /> (� <br /> PHONE:_O�t_ri' t 7-'3 FAC51MItwE: 5b - q-22� _ <br /> TENTATIVE*APPOINTMENT BATE; DEC- (0 2005- Time: A <br /> (Please allow 10 business clays from date of application submittal) <br /> I <br /> CHECK SOX TO EXPEDITE REQUEST-$93.00 FEE--RERUEST PROCESSED IN 3 BUSINESS DAYS f <br /> SIGNATURE OF APPLICANT zIlV'pl DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 5+ . c A-jIL <br /> 4p GtGi `c ,aro-& a, mac• =4Y h 5�} Iht El unit 1 <br /> 3. Street lY *4 1 Avt G 11 [)rill <br /> 4. street Q �� f- �"JMM ! <br /> s. Street 7 Pv JL aix sryC,lKfvt L- ZUnit 3 <br /> s. stet 110 c;-Vic Av-e as S- vl t f k. P. '\1 <br /> Unit 4 <br /> 9. Simi oty # <br /> 8. Street city ❑ Unit 5 <br /> So. WOO <br /> ENVIRONMENTAL.HEALTH DEPARTMENT FILES <br /> I/UN13F-RGROUND TANK(UST)CLEANUP SITE(LOP) -0 ROUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> Id OTHER CLEANUP SITE(NON-LOP) l ❑ FORD FACILITY ❑ SOLID WASTE VEHICLE <br /> t <br /> �`TIERE'b <br /> UNDEGROUND TANK(MONITORINGIREMOVAL) ❑ QOG KENNEL 0 DAIRY <br /> R G CHICKEN RANCH O PKG TREATMENT PLANT <br /> PERMIWAST_TTED FACtLrE"Y ❑ MOTEUHOTEL n PUMPER TRUCKfYARDICHFM TOILETS <br /> 0 TATToofl3ODY PIERCING 0 POOLrSP'A 0 LAND USE APPLICATION SITES <br /> © MEDICAL WASTE FACILITY 0 OTHER(PLEASE SPECIFY) <br /> 'i. List up to ten addresses in the space above. Select the type(s) of files from the list'abaye.b checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to 209 464-0138 or mail to the <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EHD#files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ten (10)days after receipt of application. The files <br /> will beheld for a maximum of five bUsIness days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A fie that is actively being worked on by EHD staff may not be immediately available for review. A new <br /> application may be submitted when the file i$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 $83.017 deposit prior to review. <br /> 5. *TENTATIVE appointment date$ 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 INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHb 4642-046 <br /> i• Ei <br />