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SAN JAI i.OUNTYPUBLIC `r1cALTri a IC � � � �I I Uy� <br /> ENVIRONMENTAL HEALTH DIVISION � �L-�r}� <br /> 304 EAST WEBER AVENUE,THIRD FLOOR 1 <br /> STOCKCON CA 95202 DEC 1 400 <br /> (209)468-3420 <br /> LIC RECORDS RELEASE APPLICAT164VIRONNIET\itASTH <br /> APPLICAN ' BUSINESSIAGENCY <br /> IVY � - 1 0`SD Q C QIJU�17CGA �5P;;W�✓'Su— <br /> �r <br /> ADDRESS � J <br /> PHONE 4? - G FACSIMILE a � 7 - ll� . <br /> TENTATIVE"APPOINTMENT DATE TIME <br /> (Plemu give 7 tD 10 buslnass days tram date of applicatlan sukHmiltal) <br /> OO <br /> CHECK BOX TO EXPEDITE REQUEST-$7 _0 E-RE UEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �p94 DATE Z l( DO <br /> FILE ADDRESS <br /> ,IFF <br /> — - -..0 �M 611 111"JIF110 <br /> t or <br /> �t y�pD.f�pv��. _5rytl..a A4® .--•Z:F9YMP- to H <br /> NVIRONMENTAL HEAL H DIVISION FILES <br /> 9, UNUEH.GROUND TANK(U5T)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> ffi OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY D SOLID WASTE VEHICLE <br /> PSf UNDERGROUND TANK IMONiTORiNGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GL'NERATOR ❑ CHICKEN RANCH M PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL 11 PUMPERTRUCKIYARDIGHEM TOILETS <br /> ❑ TATTOOtaODY PEIRCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> O MEDICAL WASTE FACILITY O PUBLIC WATER SYSTEM In OTHER(PLEASE SPECIFY ABOVE) <br /> 1, List up to ten addresses in the space above. Select the type(s) of files from the list above by checking <br /> the Appropriate box(es). At least one file type MUST be selected. Fax to [209) 404-013$ or mail to the <br /> address indicated above. <br /> 2. END will notify the applicant If any END 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 far review. Appointments should be scheduled <br /> accordingly_ , <br /> 3. A file that Is actively being worked an by EHD staff may not be immediately available for review. A new <br /> appl(catlon may be submitted when the file is available. <br /> 4_ Any file not returned in the same conditjon as released will be reorganized by END staff at the expense <br /> of the applicant, Future fife 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 atter 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> jDATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE - <br />