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k <br /> 'a <br /> SAN I IQUIN C0(JNTYFUi:3UC'HEALTH S - ICES <br /> ZIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,THIRD FLOOR _ <br /> STOCKTi ON CA 95202 <br /> i <br /> PUBLIC (209)468-3420 jl � <br /> LIC RECORDS RELEASE APPLICATION <br /> APPLICANT ✓//✓ S� �� <br /> oo (^ J r�BU�SINESS/AGENCY L-�-- <br /> ADDRESS d� tJ O �+ /7c <br /> i PfiOIY _ -1 ff <br /> rpt I� <br /> FACSIMILE <br /> TENTATIVE`APPOIITrMFNT DATE rlln� y <br /> {Please give 7 to 10 business days from date of appficaGvn submf 1) MAY 2 5 z 0 01 <br /> I' <br /> CHi;GK BOX TO EXP;Drrt REQUEST- 7 0 E— QUEST PROCESSED IN 3 5USIN1a :DAYS <br /> SIGNATURE QF APPLICANT II DATE2 � ' <br /> I[ <br /> L.,(/U/FYE ADDIp I <br /> 3 'k <br /> kA <br /> y� 3szg <br /> C <br /> S <br /> ENVIRONMENTAL HEALTH DIVISION F=ILES <br /> 1. <br /> UNPE:RGRQUND TANK(UST}CLtANUF 517.1:(LOP) CI 1­109,151NG ABATEMENT 11 0 SOLIq WASTE FACILrrY <br /> . CITIIER CLEANUP SITE(NON-LOP) CT FOOD FACILITY Q SOLID WASTE VT=MOLE <br /> UNDERGROUND TANK(MONkTORINGMEMOVAL) 17 DUG KENNEL 13 DAIRY <br /> HA7ARDGUS WASTE Gi_141; AT'QR a CHII;KEN RANCH it Q PKG TREATMENT PLANT <br /> E3 T1ERF-a PF_RMfTTED FACILITY © MOTELIHOTEL li C.] PUMPER TRUCKIYARnICHEM TDILt M <br /> TATT001BODY PEIRCING 0 FOOLfSPA i Q LAND USE APPI.JCATION SITE5 <br /> hIEDlGAL WASTE>gCIIJTY O PUBLIC WATER SYSTEM I, ID OTHER(PLEASE SFI�C"ABOVE) <br /> 1. List up to ten addresses in the space above. Select the type(s)iof files',from the list above by checking <br /> the appropriate box(es). At least one file type MUST be salactod. Fax to 209 4644138 ocn 11to <br /> al�i��ss indicated a(x vex. H <br /> 2- EHD will ratify the applicant if any EHD tiles exist An appointment for review will be confirmed <br /> approximately five business days but no Tatar than ten(70) days after receipt of application. The files <br /> Will be held for a maximum Of five business clays for review. polntments should be scheduled <br />[ accordingly, <br /> 3. A file that is actively being worked on by EHD staff may rept be lillmediately avaiilabla for review. A neer <br /> application may be submitted when the fila is available. j <br /> 4. Any file not retUrned in the same cwWition as released will be reorganized by EHD staff at the expense <br /> of the applicant- Future-#iie reviows by the same applicant may'-squire'! a$78-00 deposit prior to review. <br /> S. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 5. Applications received after 3:00 pm will be processed the next business day- <br /> • <br /> I! - <br /> CONPIRMED APPOINTMENT DATE <br /> DATE CONFIRMED _ _ PHON F_ FAX I, INITIALS <br /> �l <br /> REVIEWED YES NO REVIEW DATE <br /> 8i <br /> t <br />