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Da7i=RECEIVEOEHD LOG NUMBER <br /> SAN.�OA.+QtlIl`t COUNTY <br /> D <br /> M' D DDD E1•i viRONlvzEl`NAL HFALTH DF FAR.T1�NT <br /> 304 E Weber Ave 3"1 Floor Siockton, CA,95205 <br /> 26 99)468-3420 Fax; (209)464-0138 Web: www.co.san joaquin.ca.us/chd (01 <br /> VOL <br /> Eiv` IROtvMENT^HEALTH PUBLIC IR.FCOPDS RELBASE APPLICATION <br /> AFf'L ICANT• J�1 Y"�`•� �l I nt.�a Dti'� _BUSINESS/AG CY: Nt <br /> r• b` <br /> ADDRESS:--i� n, clsr,� v" D 4��j/ ^� <br /> PHONE:�a " '3 l -7 -3701 FACSIMILE: �.o� U <br /> TENTATIVE*APPOINTMENT DATE' <br /> Time: <br /> (Please allow 10 business days from date of application submittal) <br /> C14ECK BOX TO EXPEDITE REQU T-$93.00 E—REQUEST PROCESSED IN 3 BUSINESS DAYS 1 <br /> SIGNATURE OF APPLICANT DATE Of 11 _ <br /> Department Use Only <br /> UNIT <br /> FILE ADDRESS <br /> ,. sheet 4"7 U ,,,.,'�C Pwt W ct C ❑ Unit 1 <br /> z. Strmt aw Ll <br /> �. sH�c► <br /> CHY EJ Unit 2 QV�\ <br /> ®. .Street <br /> r. str�M q Unit 4 <br /> 8. Sheat <br /> c <br /> s. atMet G' El Unit 5 <br /> 10. Striel GI <br /> ENVIRONMENTAL HEALTH DEPARTMENT FiLES <br /> Mt UNDERGROUND TANK(UST)CLEANUP SITE(LOF) 0 HOUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) 0 FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) 17 DOG KENNEL O DAIRY <br /> CJS HAZAFibOUS WASTE G> NERATOR 0 CHICKEN RANCH 0 PKG TREATMENT PLANT <br /> \TIERED PERMITTED FACILITY © MOTELIHOTEL 0 PUMPER TRUCI{iYARDlGHENI TOILETS <br /> f <br /> M TATTOO/sopY PIERCING 0 POOL/SFA 0 LAND USE APPLICATION SITES <br /> 0 MEDICAL WA$TE FACILITY 0 OTHER(PLEASE SPECIFY) <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 be selected. Fax to 209 464.0138 or mail tb 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 be held for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3• A file that is actively being worked on by EHD staff may not be immediately available for review. Anew <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 /> 5, *TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 8, 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 /> EHO 48.02A0' <br /> aonooa • <br />