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l]3J26/2004 13:04' FAX 209 9480 <br /> DATE- <br /> 0002 <br /> DATE RECEIVEDV�•,V ••"VL <br /> SAN JOA,QUIN COUNTY <br /> RIECEWE ENvmomwNTA HEALTIRDEPARTMNT <br /> I 304 E Weber Ave P Floor Stockton,CA 95245 <br /> JUL 2 6 2000209)4b8-3420 Fax: (209)464-0138 Web:www.co.san joaquin.ca us/chd. <br /> z 0 <br /> ENVIRONMENT;HEALTH LIC RECORDS RELEASE APPLICATION <br /> P � . <br /> RP?l.1CANT: J SEBUSINESSIAGENCY: <br /> ADDRESS: 2,b i <br /> PHONE. FACSIMILF �{ d 6 Z .( — <br /> TENTATIVE'APPOINTMENT DATE: 2 c.( Time: <br /> (Please allow Zo business days from date of application Subm4411) <br /> CHECkBOX TO EXPEDITE REQUEST-$93.flo FEE--REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Deparynent use OnIY <br /> FILE AnDRESS UNIT <br /> 4. sma q!j -a �rJ 9 L ❑ Unit i <br /> z. svee! W00unit 2 � �Q <br /> 3. `4vat <br /> s s 'jnit 3 <br /> - <br /> s Wt 4 <br /> 9 gnzd a �] Unit 5. <br /> -------------- <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK{UST}CLEAHVP SITE(LOP) Q HOUSING ABATEMENT 1F SOLID WASTE FACILITY <br /> IIP OH-LOP) 0 FOOD FACILITY d SOUR WASTE VEHICLE <br /> OTHER CLEANUP$Tri(NEL DAIRY <br /> Ot UNOERGROUND TANK(M OWTORINGIREMOYAL) >�ENKENNRANGK 15 PKG TREATMENT PLANT <br /> Q HAZARDO[1$WASTE GENERATOR p MOTELIHOTEL, 0 PUMPERTRucKIYARD1cHEMT01LETS <br /> 13 TIERED PERkI"MD FACILITY d POOLISPA $ LAND USE APPUCAV014 SITES <br /> ❑ TATT00113ODY PIERCING a MER(PLEASE SPECT rim <br /> ❑ MEDICAL.WASTE FACILITY <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 209 464-013I3 or mall to the <br /> address indicated above. ointment for review will be confirmed2. EHD wilt notify the aPplicint if any EHD files exist.,. An app <br /> approximately five business days but no later than ten(10)daysfer receipt of be scheduledlioation. The tes <br /> will be held for a maximum of five business days for reVieW. Appointments should <br /> accordingly. <br /> 3. A file that is actlYely 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. se <br /> �, Any file net retamed1n the same condition as reieas lacantlmabe reorganized <br /> re airs a$93.00 deposit Pdor to review <br /> of the applicant. Future file reviews by the same applicant Y q <br /> 5. -TENTATIVE appointment dates must be confirmed With EHD staff. � <br /> 6. r4pplicatio's received after 3:00 pm Will be processed the next business day. <br /> � . <br /> x r�- '. " TIME -a; <br /> �oNF�RMED.APPoINTMF-K-T])A.rl� :r.A;a,.,- xx: :,, .,; <br /> Thr - <br /> ' . •-. �•r'• 'i,'pHOHE � - FA7�C" �'��}"iN•1�JA1-.S <br /> ' <br /> -PAT E GpNFIR1WED i <br /> FtEV1E1W YES <br /> NO REVIEW DATE ' <br /> - Stto�eax-0os <br /> WWZOU3 <br /> . I <br /> I <br />