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R002 v <br /> 10,28/2004 13:24 FAX 208 9481- SAN JOAQUIN COUNTY <br /> pATrz''REGEIVED <br /> EptVmpl`TNIEIVTAL HEALTH DEPARTMENT <br /> 304 E weber A.ve 3'd Floor S co sin j aquin.ca•uslehd 2 <br /> (209) 469-3420 Fax: (209)464-0138 Web. <br /> PUBLIC CORDS I.LELEA.SE APPLICATION <br /> SlJ� gUSWE55lAGENCY: o <br /> APPLICANT: <br /> ADDRESS: FACSIMILE; <br /> PHONE: ru10:—��— <br /> TENTArW APPOINTMENT DATE: <br /> (P{Dasa allow days <br /> tram data of appliention subm'nta� <br /> 10 business <br /> REQUEST-i�3•�FEE-RE PROCESSED IN 3 6USME55 DAYS <br /> © CHECK SOXTO EXPEDITE REQ DATE <br /> Department Use Only <br /> SIGNATURE OF APPLICANT UNIT <br /> FILE ADDRESS _•� j =.; : d.,A,�.. ;;.. Unit f <br /> I Q <br /> n u;i5or� G k , V <br /> z. sum 3i tt N f <br /> Unit 2 \0S <br /> Q N. Unit 3 l� <br /> yn ro G <br /> Unrt4 <br /> E v ey ��J ❑ UnitS <br /> r. aex l T �tft Gk ,i. . r 1- l <br /> su.a cA <br /> � qhs w G <br /> T FILES <br /> ENVIRONMENTAL HEALTH DEPAR MENT yg soLm WASTE FAcltm <br /> ❑ HOUSING ABATEMENT ❑ SOUDWASTEv£H1CLE <br /> it UNDERGROUND TANK OST <br /> CLEANUP <br /> SITE lLOpl d FOOD FAMI-r[y M DAIRY ` <br /> M OTHER CLEANUP SITE(NON-LOP1 ❑ DOG KENNEL A.PKG TREATMENT PLPNTHEM TOILETS <br /> §� UNDERGROUND TANK(MO""'!"NGIFLEMOYALI ❑ CHICKEN RANCH a PUMPER•.RUCK1YARD! <br /> HAZARDOUS WASTE GENERATOR ❑ MOTEUHOTEL a LAND USE APPLICATION,rres <br /> 4 TIERED pERttrrTFD FACILITY ❑ pOOLISP E SPECIE•'!) <br /> ❑ TATTOOBOOy PIERCING ❑ OTHER(PLEASchecking <br /> ❑ MEDICAL WASTE FACILTTY s of files from the list above by <br /> List up to ten addresses in the space above. Select the tyle( ) <br /> �" appropriate hox(es). At least one Tile type MUST be selected, Fax to 2G9 464-0133 or mail to the <br /> the app P ointment for review will be confirmed <br /> address indicated above.cant if any EHD files exist. An-appointment <br /> after receipt of application. The files <br /> END will notify the app s but no Eater than ten(10) Ys ointments should be scheduled <br /> approximately five business day s for review. APP <br /> will ba held for a maximum of five business day not be immediately available for review. A new <br /> accordingly. Din worked on by EHD staff may <br /> 3 A Tile that is actively being EHD staff at the expe�e <br /> application may be submitted When the file is available. require a$93.00 deposit prior to ceview <br /> the same applicant may <br /> 4 Any file not returned in the same condition as released will m reorganized y <br /> ws by <br /> of the applicant. Future file re, is must be confirmed with EHD staff. <br /> 5. <br /> 'TENTATNE appointment dates m Processed the next business day. <br /> 6 Applications received after 3:00 pm will e P ry A` <br /> • : RIME %». ..:. ::.':_... "�l','_-•`y <br /> b <br /> iNTMN <br /> p <br /> DATE <br /> Ap T` - --� <br /> .. .. � fCIpLS'. <br /> P Fes.. <br /> .,.. . . �T.r- •ePHONE _, <br /> DATIGQNFIRMED <br /> • , REVIEW!DATE: <br /> NO <br /> YES '-,:.:.;• <br /> REVIEWED ' <br /> . u+o.a-azAa <br /> ervt�� <br />