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Applications Will Be Pr ed When Submitted Properly Completed. Be S�o Sign The Application <br /> UGST PROGRAM APPLICATION / <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/OR IF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR �A y�/ L FOOD ESTABLISHMENTS.HOUSING Make <br /> CONTRACTOR AND/OR L \V'r1: PUBLIC POOLS,WATER SAMPLING <br /> BROKER AND/OR REAL ESTATE INSPECTIONS LIC. No. -- <br /> icFNSE AND/OR POULTRY RANCHES AND KENNELS Regist. No <br /> 3TRATION MISCELLANEOUS SERVICES <br /> Color <br /> i. BER - - - - --- <br /> "Application Date_ 11-16-90 -_ Business/Name To Appear On Permit <br /> ,Type Permit/Service Requested: FILE REVIEW/RECORD_RELEASE <br /> sApplicant Name SIERRA ENVIRONMENTAL SERVICE&�rjWSLIE A CLEMENT, P 0 BOX 2546 <br /> MARTINEZ x CA 9455s%siness Telephone No._ _ Emergency Telephone No. <br /> a Property Location/Address 700 DOUGLAS, 6502ii-PACIFIC AVE, 501 LINCOLN CNTE <br /> aProperty Owner ___ - —____ Address _ — <br /> [Operator's Name Address <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators —.. -- <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units — ❑ CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> :ENNEL/Runways /Animal Population No. -- No. of Confining Cages__ <br /> Sewage Disposal Method - -- - -- <br /> Solid Waste Disposal Method -- <br /> Water Supply Source Animal Waste Disposal Method — <br /> 6. ❑ CONSULTATION FEE -- - - -- <br /> 7. ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection[] SampleD Title Company — - - -- <br /> Sewage System Inspection ❑ Address _ Tele. No. s® p® <br /> Escrow No. --- — PAYMENT <br /> Seller Seller Address RECEWED <br /> - <br /> Telephone No. _— Seller Agent Name —._ 181991 -- <br /> Service Request For Date -- — -- u�t 3 <br /> I hereby certify that I have prepared this application and that the work will be done in accordarpUOLICMi HNE AVL S RVI y✓ <br /> ES <br /> ordinances, state laws. ENVIRONMENTAL HEALTH DIVISIOP! <br /> APPLICANT'S SIGNATURE X Title Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SIT ❑ H ❑ January 1 8 Received By January 31 ❑ July 1 S Received By July 31 <br /> REMIT <br /> BASE EXPLANATION REMITTANCE $ AMOUNT DUE CHECKED <br /> A E DATE REMITTED AMOUNT <br /> FEE $50 .00 FILE' REVIEW/ ECORD RELEASE <br /> LESS <br /> PRORATION - PENALTIES WILL BE CCOUNTS <br /> PLUS 0 DAYS FROM BILLING DAT <br /> PENALTY <br /> OTHER _ <br /> OTHER $50.O <br /> Received by Date Receipt No Permit No. Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />