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F'(-A.1L Di/Ld <br />tHD LOG NUMBER <br />02/01/2002 18:84 2094E: 8 AGE STOCKTON <br />SAN JOAQUIN CO TYPUBLIC HEALTH SERVICES <br />/4 -g i__.*4 v iiW1,41111L.P4 7.___,Aks h 304 EAST WEBER <br />PUBLIC RECORDS <br />STOCKTON <br />AVENUE, THIRD FLOOR <br />I fr11- FICP1I- I n IJIVIJIVIN gr. 742, <br />CA 95202 <br />209) 468-3420 <br />RELEASE APPLICATION <br />APPLICANTSU2-al 1••• Al illk diiSI ESS/AGENCY 1 . <br />_ .1._ .......„ <br />I il i 0 ‘.6'd &Or? 1 /I Men lat. <br />ADDRESS 39 SA00 °PO • <br />PHONE (RO 4 ) c//De FACS MILE <br /> <br />TENTATIVE' APPOINTMENT DATE ,a0 0 4P,_ TIME i <br />(Pleas - give 7 to 10 b4 :ss <br />?!fij <br />ri <br />CHECK BOX TO EXPEDITE REQU - 8(0 EE - E • ) <br />SIGNATURE OF APPLICANT Nur g AG AL" <br />da s from • to of application submittal) <br />i <br />' - q :.5 D IN 3 BUSINESS DAYS <br />/ DATE 0?/0//00 <br />i <br />Fl E ADDRESs <br />e -rWIIIIMI N1111.111DEEN • RA f a.c) a cc trz, <br />3 0 0 35.?-4 F B _ , <br />.) ,. . . a i • • <br />1 i 4 • , A . SrIts C-ItO <br />• <br />* • s I a r , 0% o 10, • I 4 p._ 0 b <br />Ago A 114111111124=1 <br />J;1 5 5.a l.1 • raT, <br />ENVIRONMENT <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) CI 1-10 <br />UNDERGROUND TANK (MONITORING/REMOVAL) 0 DO <br />TIERED PERMITTED FACILITY <br />RA <br />OTHER CLEANUP SITE (NON-LOP) 0 FOOD <br />HAZARDOUS WASTE GENETOR 0 CHI <br />1 <br />0 MO <br />0 TATTOO/BODY PEIRCING 0 POOL/SPA <br />0 MEDICAL WASTE FACILITY 0 Pu:LIC <br />List up to ten addresses In the space abo <br />the appropriate box(es). At least one file <br />L HEALTH DIVISION FILES <br />SING ABATEMENT 0 SOLID WASTE FACILITY <br /> <br />FACILITY 0 SOLID WASTE VEHICLE <br />in KENNEL DAIRY <br />KEN NCH 0 PKG TREATMENT PLANT R,A <br />EL/HOTEL. 0 PUMPER TRUCK/YARD/CHEM TOILETS <br /> <br />- in LAND USE APPLICATION SITES <br />WATER SYSTEM 0 OTHER (PLEASE SPECIFY ABOVE) <br />e. Select the type(s) of files from the list above by checking <br />ype MUST be selected. Fax to (209) 464-0138 or mail to the <br />address indicated above. <br />EHD will notify the applicant if any EHD fil <br />approximately five business days but no I <br />will be held for a maximum of five busine <br />accordingly, <br />1 A file that is actively being worked on by <br />application may be submitted when the fil <br />4, Any file not returned in the same conditio <br />of the applicant. Future file reviews by th <br />*TENTATIVE appointment dates must be <br />Applications received after 3:00 pm will b <br />s exist. An appointment for review will be confirmed <br />ter than ten (10) days after receipt of application. The files <br />s days for review, Appointments should be scheduled <br />HD staff may not be immediately available for review, A new <br />is available. <br />as released will be reorganized by EHD staff at the expense <br />same applicant may require a $78.00 deposit prior to review. <br />onfirmed with EHD staff. <br />processed the next business day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE