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FROM NQq Erxrtr roll stat Pw�e eetr.IVEu SAN Irll,r'ir DEC 2 3 2002 �I�•ivl�;:Ir�lt�;�iPUE APPLICANT 14 b rA PHONE NO. : 209 369 4228 Dec. 23 2002 12:24PM P3 JGAQUIN COUNTYPUBLIC HEALTH SERVICES EHD 4e0 NUMER ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, THIRD FLOOR STaCKTON CA 95202 (209) 468-3420 LIC RECORDS RE=LEASE APPLICATION I BUSINESSIAGENCY L10A C/�(��/'�t'1✓IiLI • -- ADDRESS ZZ n( goV.SA-. L (,Oj , C �$ I.50- '/G PHONE &05)i &7-.376 1 FACSIMILE -6L9> 5W -Yzz.a TENTATIVE" APPOINTMENT DATE (0 7 on TIME (Please Diva 7 to 10 business days from date of appl(catlon submittal) • CHECK BOX TO EXPEDITE REQUEST- 58900 EEE - RE T P OCESSED IN 3 BUSINESS DAYS Un SIGNATURE OF APPLICANT �r DATE %2&-41-) Z AKII f.JC�Y�C 'tLrik QL,-w.i f j ENVIRONMENTAL HEALTH DIVISION FILES RI UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY 2r OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE ST UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY 04' HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT ❑ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCKIYARDIC14EM TOILETS ❑ TATTOOl80DY PEIRCING ❑ POpUSPA ❑ LAND USE APPLICAnON SITES • 0 MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM t$ OTHER (PLEASE SPECIFY ABOVE) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address Indicated above. 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A Nie that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $89.00 deposit prior to review. 5. *TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE. DATE CONFIRMED TIME -PHONE FAX REVIEWED YES NO REVIEW INITIALS THIS SIDE EHD STAFF USE! ONLY PROGRAM ••-I • � ' _ IYllli \��IU11�171��111 ta'I:I-..;�� - r J � u �.i ,11■L'II _ � � �,,111�.=,rte .fit• _ ,, � � .�.t. -111111111111111,1��11=11111111111111, Y/�►��i. _.•, � car: ^, . ■�■I�■i�l■Ili■�Ilr AKII f.JC�Y�C 'tLrik QL,-w.i f j ENVIRONMENTAL HEALTH DIVISION FILES RI UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY 2r OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE ST UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY 04' HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT ❑ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCKIYARDIC14EM TOILETS ❑ TATTOOl80DY PEIRCING ❑ POpUSPA ❑ LAND USE APPLICAnON SITES • 0 MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM t$ OTHER (PLEASE SPECIFY ABOVE) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address Indicated above. 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A Nie that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $89.00 deposit prior to review. 5. *TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE. DATE CONFIRMED TIME -PHONE FAX REVIEWED YES NO REVIEW INITIALS