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r <br />0/04/2004 10:01 <br />DATE RECEIVED <br />SAN JOAQUIN COUNTY <br />N'VIRONWNTAL HEALTH DJEI'ARTMENf <br />304 E Weber Ave 3 Floor Stockton, CA 95205 <br />0 C T 0 4 2004 Xv55 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www_co.san joaquizn-ca.us/ehd <br />ENV! k01 ,ii.L."'' f tlr- II i H <br />PEES MlTSE vi+, . PUBLIC RECOIt�?S RB�.EASE APPLICATION <br />`s o <br />APPLICANT: BU <br />, �a�•ll d g • 6INEWAGENCY. <br />ADDRESS: `7 lam" <br />PHONE: - 9� FACSIMILE:__"' <br />TENTATIVE` APPOINTMENT DATE: I-+Tlme' 4 A --A J . <br />(PlMe allow 10 business days front date of application subMKW) <br />® CHECK BOX TO EXPEDITE RE EST. $93.00 FEE - RFQUtST PROCESSED BI 3 BUSINESS DAYS <br />SIGNATURE. OF APPLICANT V DATE <br />Uss Only <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 <br />❑ Unit 3 <br />❑ Unit 4 <br />❑ Unit 5 <br />❑ HOUSING ABATEMENT ❑ SOLID WASTE F x,111 jr u <br />❑ fU1NDERG�/yyRO�pU����N��D TANK QM <br />(UST} CLEANUP SITE (LOP) 13 FOOD FACILITY DO soLio WASTE �f ijll 1 �1q <br />D OTHER CLEANUP SITE (NON -LOP) - <br />G1 UNDERGROUND TANK (MONITORINGiREMOVAL) ❑ DOG KENNEL p PKG TREATMENT PLANT ��� <br />❑ HAzARDOUS WASTE GENERATOR a CHICKEN RANCH <br />TIERED PERMITTED FACILITY ❑ MOTELIHOTEL O PUMPERE APPLICATION <br />T TOILETS <br />D <br />D TATTOOIBODY PIERCING • '❑ POOLISPA ®LAND USE APPLICATION SITES <br />® MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECtF1t7 <br />1. List up to ten addresses in the space above. Soled be Fax files f 209 a the list a38 or by mail�to he$ <br />the appropriate box(es). At least one file type M <br />USTaddress indicated above. <br />2- EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br />approximately fire 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 EHb staff may not be immediately available for review. A new <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 />6. Applications received after 3:00 pm will be processed the next business day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED <br />" PHONE FAX- INITIALS <br />REVIEWED YESNO REVIEW DATE. . <br />av : Fre / FIC) v", L C �n 4L&r ! �OWC467 - - Vf �(,� V f7 1�'.�"'' <br />