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0 <br /> 09/04/2002 10:38 2694F71118 AGE STDCKTDN PAGE 01/01 <br /> Uplk Nkl:tIVGD Q10lAe NIRIBCR <br /> 14w ' SAh�L7AQUIN COUNTYPUSLIC HEALTH SERVICES <br /> / VIRONMENTAL HEALT IVISION � <br /> 4 FAST WEBER AVENUE,T &OR <br /> RE��pp��nn D STOCKTON CA 95 <br /> Il\Vl )468-3420 <br /> LICRECORDS9RELEASEAPPLI 3 _ 51Z M <br /> I I <br /> NN� ^ a:* <br /> SAPPLICANT !lY �l USINESSIAGENCY <br /> ENVIRIHONFE <br /> & auj 4;09) <br /> o C I ffLD;) <br /> PE ^ 00 ) /y <br /> O FACSIMILE_ / - <br /> PPOINTMENT DATE O a TIME ordl ep <br /> ' S (Please ive Y to la burin dofrom de of application submittal) PERMIT <br /> 1 I CHECK BOX TO EXPEDITE REQU T-$78.00 EE-REQU E ED IN 3 BUSINESS DAYS i <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS <br /> C r <br /> r <br /> I I ,Fr oA s 7 n <br /> � <br /> 5 1YI n <br /> rnn <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR O CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEM-TOILETS <br /> ❑ TATTOOIBODY PEIRCING ❑ POOLISPA 0 LAND USE APPLICATION srTES <br /> ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM 0 OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses In the space above. Select the type(s) of flies 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 to the <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EHD flies 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 flies <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. 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$78.00 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 PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> D/oo t� mroewo <br />