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10- 4-04; 4: 17PM; - ;2099836960 z '- <br /> f'�10/04/2004 14:39:',: .4648? ENVIRONMENTAL )LTH PAGE 01 <br /> DATE RECEIVED SAN JOAQUIN COUNTY � <br /> I L�1�I���I `;'� ir'•'� ENVIRONMENTAL HEALTH DF-PARTMENT <br /> a 304 E Weber Ave 3"1 Floor Stockton, CA 95205 <br /> 0 C T 0 4 2", )468-3420 Fax: (209) 464-0138 Web: v;Nvw.co.sanjoaquin.ca.us/ehd <br /> Rel57 <br /> PIT$LIC RECORDS RELEASE APPLICATION _.__ <br /> APPLICANT: �ob Sicy{r�c�/ SUSINESSIAGENCY: ,�avarir s /ISseLiars <br /> 1 ADDRESS: '26 Z 4 l ✓/ fl r �{ klan� <br /> LPHONE: (20 f) '7k3 - 4,F/o FACSIMILE:. 'Ff?- 6 14 v <br /> TENTATIVE'APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> El CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT .�-� ✓✓J/—�' DATE <br /> /a� y- oY <br /> Department Use Only <br /> UNIT <br /> FILE ADDRESS <br /> e iverl. u Z ° '/' ❑ Unit 1 <br /> i 2. Street GI <br /> O ❑ Unit 2 .> il_iq <br /> 3. Street f � <br /> ciUnit 3 1 A <br /> 5. 3veet (;1 � y <br /> C1 <br /> e. Skit <br /> Unit 4 <br /> 7. sjKet <br /> a <br /> q <br /> e, sired <br /> city <br /> 9, Sheet <br /> ci <br /> 10. Sheet <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> O HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> UNDERGROUND TANK(UST)CLEANUP SITE(IOP) D FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) 0 DOG KENNEL ❑ DAIRY <br /> O UNDERGROUND TANK(MONrrORING/REMOVAL) 13 CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> O HAZARDOUS WASTE GENERATOR 0 MOTEL/HOTEL 13K/ <br /> PUMPER TRUCYARD/CHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY 0 POOLISPA t� LAND USE APPLICATION SITES <br /> ❑ TATTOO/60DY PIERCING0 OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <br /> 1. List up to ten addresses in the space above. MUSTlect the <br /> be s ected f Fax(s) ofilefrom <br /> (209)464.0138 or myal to tcheckhe <br /> the appropriate box(es). At least one file typ <br /> address indicated above. ointment for review will be confirmed <br /> fy the aplic <br /> 2. EHD will notipant if any EHD files exist. An app <br /> ys but no later than ten(10)days after receipt of application. The files <br /> approximately five business Ba <br /> e business days for.revlew. Appointments should be scheduled <br /> will be held for a maximum of fiv <br /> accordingly. <br /> ely <br /> 3. A fife that is activbeing worked on by END staff may not,be immediately available for review. Ane <br /> application may be submitted when the file is available. at expens <br /> 4. Any file not returned In the same condition as released ant mawill be y require a$93.00 eorganized Hdepostaff prior revie <br /> of the applicant- Future file reviews by the same app Y <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 /> �! <br /> PHONE FAX INITIALS <br /> DATE CONFIRMED ` <br /> REVIEWED YES NO REVIEW DATE <br /> ' EHD 18-02-008, <br /> )UM2003 <br />