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06/28/2005 09:09. FAX 209 9480621 U.002 <br /> . GIIU VVV IVvv1V ti <br /> DATE RF-CElvl=o SAN JOAQUIN COUNTY <br /> � <br /> �?.I <br /> Engp,ONNL ENTAL aALTH DEPARTMENT <br /> p <br /> Ec1!� 304 E Weber-Ave 31"Floor Stockton,CA 952.05 <br /> (20.9 -3420 Fas: (209) 464-0138 Web: )NNvNv.co.san-joaquin.ca.us/chd. <br /> H LIC RECORDS RELEASE A.PPLICAMN <br /> APPUCMfl BUSINESSIAGENCY: <br /> ADpRESS: 2 <br /> PHONE: FACSIMILE: _ <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of aWlcation sutzm'ttal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.04 FEE,REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT .••�� �enM► DATE �Q <br /> Department use only <br /> • - - UNIT <br /> FILE ADDRESS <br /> Wit 1 <br /> a <br /> �. suad a D � Unit 2 <br /> ., soca a <br /> ty <br /> s. s� <br /> Q� <br /> / U unit 3 <br /> aly <br /> 0 <br /> 6. SU-d <br /> G Unit 4 <br /> a <br /> ❑ Unit 5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> E3 HOUSING ABATEMENT *_SOCIO WASTE FACILITY <br /> UNDERGROUND TANK(US-n CLF-ANUP SiTI_(LOP) ❑ FOOD FACILITY ❑ SOLlo W ASTE vEN1CLE r <br /> OTHER CLEANUP SrrE(NON�OP) 0 BOG NNEt. 'A DAIRY <br /> �.UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH f PKG TREATMENT PLANT <br /> 41LHA7AROou5 WASTE GENERATOR ❑ MQTFLl4 0TEL ❑]PUMPERTRUCKIYARQIcHEM T01 <br /> ❑ T{ERED PERMnTED FACILfrY IC POOt�PA $k USe APP PLIC T10N SfTEs <br /> ❑ TATTOGISODY PIERCING VC OTHER(PLEASE SPECIFY) <br /> Q MEDICAL WASTE FACILITY <br /> , List up to ten addresses in the sax to pace above, Select the type(s) of files from the list above by checking <br /> 1 <br /> the appropriate box <br /> addresses <br /> At least one file type MUST be selected. F 209 46,4-0138 or mail to 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 rive 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 /> ked on by EHD staff may not be immediately available for review. nes <br /> 3. A file that is actively being wor <br /> application may be submitted when the file is available- <br /> 4- Any file not returned in the same condition as released will he reorganized by EHD staff at the experts <br /> of the applicant. Future file reviews by the sarne applicant may require a$93.00 deposit prior to revie' <br /> 5. *TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will,be processed the oextbusiness day. <br /> I �._. <br /> [1h1E <br /> r;1RE <br /> MENTo-ATEI ONE PHIEWED YES NO REVIEW DATE <br />