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200�j4C� �f111$ AGE STOCKTON PAGE 03./01 <br /> M Inl I�`�'� ll A (,, Uf N COUN YPUBLIC HEALTH StnaVICEs I-00 LOG NUMBER <br /> APR n 7 2003 ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> ENVIHUIVMENT HEALTH STOCKTON CA 95202 <br /> PERMIT/SERV (zos)468-3420 <br /> � SLIC RECORDS RELEASE APPLICATION <br /> I 3c� <br /> APPLICANTtiza BUSINESS/AGENCYrt/� L�Q' CLQ�nu�tQ/gym n7 j J <br /> ADDRESS [ )�hQ�► A <br /> PHONE Cao4 7(J! <br /> FACSIMILEv <br /> TEkTATIVE*APPOINTMENT DATE'S QA TIME <br /> (Ploase give 7 to 10 business days from date f applicatlon submiktal) <br /> CHECK SOX TO EXPEDITE REQ U T-SIM,00 FEE—REQUEST ROCESSED IN 3 BUSINESS DAYS <br /> �' <br /> SIGNATURE OF APPLICANT DATE _ <br /> FILE ADDRESS <br /> h <br /> � r- <br /> f ♦i f t ♦ 4f -/ ••d tea... A.y <br /> ' If If ♦f It — <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LAP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE I-ACIUTY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONrrORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PI(G TREATMENT PLANT <br /> Q TIERED PERMITTED FACILITY O MOTEL/HOTEL ❑ PUMPER TRUCIVYARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PEIRCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE spmr-y ABOVE) <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(209 464-0138 or ml il to the <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ten(10)days after receipt of aloplication. The filas <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 review. 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 revlews by the same applicant may require a $78.00(inpo cla.to x19oA ' <br /> 5. *TENTATIVE appointment dates must be confirmed with EHD staff, 9 =` <br /> 6. Applications received after 3:00 pm will be processed the next business clay. fti.-4 <br /> CONFIRMED-APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> 11H 09 14 01103MG — _— <br />