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A N C MEN AL HE LTH DI tSIC1, <br /> SAN J EALTH SER' ES <br /> �. IRON � <br /> �D � <br /> 304 EAST WF-RER AVENUE,THIRD FL.00lt <br /> JUN 2 9 ZOQO STQCKTON CA 957-02 <br /> (2W)Lazo <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELF-ASE APPLICATION <br /> pyL f -C'.0 A- RMI NESiS1A�GENCT <br /> qV PLtGANT <br /> ADDRESS <br /> - <br /> PHOTIME <br /> C) <br /> �,CjfaTATIVE"ApPOlNTrLENT DATE <br /> to S4 bu�iYtQaSdaysfrun dart ofapPlioarlan aubmitWl} v <br /> ,t4� <br /> (POas>a6g 8 <br /> ICU CHECK SOX TO EXPEDITE REQUES-T-VEW FEE--RFQ <br /> SEM)IN 3 BU3INF_Ss'0AY0 <br /> oATE <br /> SIGNATUp,F-OF APPLICANT <br /> oril <br /> -7- <br /> a <br /> Z <br /> 1 pr=S <br /> X5C) <br /> c <br /> ENVIRONMENTAL HEALTH 61VISION FILE <br /> SOLID WASTE FACILITY <br /> t)NI)ERGRoUNDTANK PUTT CLHANI.IF SITF(LOP) 0 HOUSING ABATEMr-HT ca SOLID WASTE VEHICLL <br /> OT14ER CLEANUP SiTn(NON-LOP) C] FOOD FACILITY © RARY <br /> UNCERGROUND TANK(MON MORIKOtREMOVAL} 0 000 KXNNEL In pKG TE4E.ATMEICr PLANT <br /> MAZARI]OUS WAsTE GENERATOR C1 CHWAC EX RANCH ❑ F%fAPF.RTR.UCKr'fARD[CHEIY TOILETS <br /> TIERrmg pVRHMi'ITED FAC2JTY n MQTELISIOTEL p LAIJID USE APMACATWN SITES <br /> 10 TATTCKXBGDY PEIRCING d POOL0 OT jp.K(PLEASE SPECIFY ABOVE) <br /> ID MEDICAL WASTE FACILITY � PlI8LIC WATER SYST�A <br /> 1, t,ist up to ten address in the space above. Select the type(s)a# Is frnrrl the list ab+ave by checking <br /> the appropriate box(es). At least One file type musT be seleoteti. Fax to <br /> 73S or ail M t <br /> adder. ated above. <br /> 2. EHD will notify the&ppilaant if any EHO fllbs OXIst. An appointment for review wilt be aonfirrned <br /> agproXirnately five busiMOSS days bat no later than tern(10)days after receipt of application. The filar <br /> will be rleld for a m"imum of five business dayS for review. Appointments should be scheduled <br /> accordingly. ENI] staff May not be Immediately avaltahte for review. A new <br /> A file that is actively being worked on by Y <br /> applicaUan may be submttted when the file is available. at the <br /> d. ArN file not returned in the sante condition as re leaxed will ha reorganized�a Q depy EHD os t prior to evnew. <br /> of rite aAAiicat�t f=uture file revieWs by the same applicant may require <br /> *TENTATIVE appalntmerlt pates must be confirmed wit#t EHF3 staff. <br /> 6. Apprioatlons receiVed after 3�Da pm_rrili be processed the next business day, <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED <br /> PHONE FAX INITIALS <br /> R�IEINEU YE5 TIU REVIEW L7ATE <br /> �r vo u o TOTAL P.Q2 <br />