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f <br /> i'kA-SEAECFJYEp <br /> SAN JG <br /> JUIROIN COUNTYPUBLIC HEALTH SLICES <br /> _ Ef+1VNMENTAL HEALTH DIMS 0 <br /> 7 304 FAST WESER AVENUE,THIRD FLOOR &,5-7 <br /> sTOCKTON CA 95202 <br /> (209)4$8-3420 <br /> LIC RECORDS RELEASE APPLICATION <br /> n. <br /> APPLICANT BUSINESSIAGENCY <br /> ADDRESS 93 '97 , SA 0 <br /> 13110w0'?0 <br /> 91 V10 7:�V-617 , FACSIMILE _N <br /> VE'AOIhThtEflDATE T1E 10 <br /> rf <br /> oTENTATI (Pled giva 7 to 10 I��inoss Any-5 <br /> s <br /> frort data of appliCatlon submittal) �u i <br /> CHECK BOX TO EXPEDITE RB UE -'718.00 FEE--ReQUiv^T' ROC1= ED IN 3 BUSINESS DAYS <br /> EGNATURE OF APPLICANT DATE -Mlle— — / — <br /> FILE ADEIRESS <br /> F11— <br /> q0Q A) <br /> 3 •7-45 I� 25 sic. <br /> r ,2 <br /> �. It 35 mac. GD <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(LIST)CLEANUP Sll"E(LOP) O' HOUSING ABATEMENT ❑ SOLID WASTE I"ACIUTY <br /> Ci ❑ <br /> OTHER CLEANUP$iY'iw(NON-I.DP) E=00fl FACILITY SOLID 1i1lAS7E VEHICLE <br /> UNDERGROUND TANK(MONITOR[NGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZAIR12OUS WASTE GENERATOR 0 CHICKEN RANCH 13 PKG THF-ATMENT PLANT <br /> 71E;REDAERMn-rEC)FACILITY 0 WrFELMOTEL t7 PUMPER TRUCKlYAR=HEM-TOILETS <br /> ❑ TATrOOi QUY PORCING LD POOUSPA a LAND USE APPl3CATION SITES <br /> Q MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ CMHER(PLEA5E SPECIFY ABOVE) <br /> 1_ List up to ten addresses in the spaCo above. Select the type(s) of files from the list above by checking <br /> the appropriate box(es). At least one file type MIDST be selected. Fax to (209)_464-0'134.or mail to the <br /> addres*indicated above. <br /> 2. EHO will notify the applicant if any END files exist. An appointment for review will be confirmed <br /> approxirnately five business days but no later than ten(10)days after recelpt of application. The files <br /> will be held for a maximum-of five business days for review. Appointments should be scheduled - <br /> accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be Immediately available for reviow. A new <br /> application may be submitted when the file is,available. <br /> 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense <br /> of the applicant. Future file reviews by the same applicant may require a$78.00 deposit prior to review. <br /> 5. "TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6- <br /> Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APFOINTFAENT DATE TIME <br /> DATE CONFIRMED _ PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> Els 0[f 14 ai10.V90 - — --- <br />