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DATE REr.E1VE0 BE <br /> SAN JO.,UlN COUNTYPUBLIC HEALTHVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EA§T WESER AVENUE, THIS FLGOR <br /> - STOCKTON CA 95202` <br /> ), '� (209) 468-3420 <br /> �- � LIC rRECORDS RELEASE APPLICATION <br /> T 1. <br /> APPLICANT Q_ '-0. Qit5, t ,S=t BUSINESSIAGENCY-6x)�cr- <br /> ADDRESS ��V�C.J <br /> PHONE -FACSIMILE MAY 2 8 2002 <br /> TENTATIVE'APPOINTMENT DATE_.. S OZ-. TIME 7Q' /(-EUVIR0NM ENT HEALTH <br /> (Please gi�vYe 7/1/0�o mess s fro to of licat/Iion su mittal) PERMIT/SERVICES <br /> CHECK BOX TO EXPEDITE REQUES -$87.00 FE�EQU�ROCESSEl�IN SINES AYs <br /> SIGNATURE OF APPLICANT o C ` DATE <br /> CaiPl � Lvv- J <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> i <br /> C I <br /> �nol <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 1,SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOO/BODY PEIRCING ❑ POOLJSPA ` ' ❑ LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ 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) 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 files <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 $87.00 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 />