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iQJUVL/VVL <br />03/11/2002 09:17 FAX 209 948 0821 <br />RLEINFELDER END LOG NUMBER <br />V DATEREC D SAN 16Q.UIN COUNTYPUBLIC HEALTH #VICES <br />jjt <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, THIRD FLOOR <br />sTOCKTON CA 95202 <br />(209) 468-3420 <br />n� <br />m= ) I I ftr110''1A mLIC RECORDS RELEASE APPLICATION <br />/moi M °LKLen Fe Ider <br />APPLICANT ^ p p car- vG�=BUSINESSIAGENCY <br />ADDRESS a D �" F �✓I r•-J-I�. S'♦•r� ,L <br />�. FACSIMILE <br />PHONE �3 /S -/ <br />7 TIME <br />TENTATIVE* APPOINTMENT DATE data of pllcatlon submittal) <br />(PIaat�10 n0ss aY <br />F � � �g IN 9 BUSINESS DAYS x� <br />El CHECK BOX TO IXPEDfTER�� DATE <br />SIGNATURE Of APPLICANT <br />nw .r...- _.._ - <br />PROGRAM ELEMENTS SEARCH <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />.CrSOUD WASTE FACILITY <br />.2T SOLID WASTE VEHICLE <br />❑ DAIRY <br />❑ PKG TREATMENT PLANT <br />❑ PUMPER TRUCKIYARD/CHEM TOILETS <br />❑ LAND USE APPLICATION SITES <br />❑ OTHER (PLEASE SPECIFY ABOVE) <br />MAP,. <br />&ErUNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ FOOD FACILITY <br />j2r OTHER CLEANUP SITE (NON -LOP) <br />kip++ c54--rr <br />.Cr UNDERGROUNDTANK(MONROfiINGIREMOVAL) <br />yl HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />ID <br />❑ MOTELIHOTEL <br />.0 -TIERED PERMITTED FACILITY <br />❑ pOOUSPA ' ' <br />S-lockd. <br />O PUBLIC WATER SYSTEM <br />.5•I•a�4te1 <br />LAV <br />pz;zn <br />Stk+a.. C4 .s+. <br />S for cir C��(-<r/ciah <br />S.A' <br />Cle <br />SfiAc�c Fm+ C� <br />X335 <br />G M:ner <br />S4' <br />Gi1w.414. Cc <br />✓J <br />?pa3 <br />t M%ri k° <br />S-- <br />SlmCkio Cr <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />.CrSOUD WASTE FACILITY <br />.2T SOLID WASTE VEHICLE <br />❑ DAIRY <br />❑ PKG TREATMENT PLANT <br />❑ PUMPER TRUCKIYARD/CHEM TOILETS <br />❑ LAND USE APPLICATION SITES <br />❑ OTHER (PLEASE SPECIFY ABOVE) <br />MAP,. <br />&ErUNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ FOOD FACILITY <br />j2r OTHER CLEANUP SITE (NON -LOP) <br />El KENNEL <br />.Cr UNDERGROUNDTANK(MONROfiINGIREMOVAL) <br />yl HAZARDOUS WASTE GENERATOR <br />❑ CHICKEN RANCH <br />ID <br />❑ MOTELIHOTEL <br />.0 -TIERED PERMITTED FACILITY <br />❑ pOOUSPA ' ' <br />17 TATT001BODY PEIRCING <br />O PUBLIC WATER SYSTEM <br />;2�• MEDICAL WASTE FACILITY <br />List up to ten addresses in the space above. Select the select) of files from the list above by checking <br />the appropriate box(es). At least one file type MUST be selected. Fax to 209 464.0738 or mall to the <br />address indicated above.eview Will be confirmed <br />2. approxiimatetly five business days buHDno late®than ten (0) days after receipt of <br />application. scheduled files <br />will beheld for a maximum of five business days for review. Appointments should be scheduied <br />accordingly. <br />3, A file that is actively being worked on by EHD staff may not be immediately available for review. Anew <br />application may be submitted when the file is available. at the expense <br />q. Any file not returned in the same condition as released will be re er9�aie a $87y 0 deposit prior to review. <br />of the applicant. Future file reviews by the same applicant may q <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 <br />TIME <br />DATE CONFIRMED PHONE FAX <br />___ vcc NO REVIEW DATE <br />INITIALS <br />