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-- - <br /> AN p►{:iuilV GQU�t7YFUBLi� H V3Si iti;ES S <br /> 14 <br /> �HViRpNMi~NTAL HEALTH <br /> 304 EAST WEDER AVENUE.THIRD FLOOR <br /> STOCKTON CA 95202 <br /> A (209)468-3424 <br /> y <br /> LIC RECORDS f�i;LASE APPLICATION <br /> 81151N>r5SlAGENCY Q11Q17 D "C <br /> APPLICANT <br /> AUf i3E5S L7 V t� 4U!1 S 4 l� T CA 1 <br /> PHONE Q — t FACSIMILE (� 0V A�1 /� <br /> V��t CUh O y r Y1kIlE �+F A,\ <br /> TENTATtVI~*AI'i'G?INTMEN7 DATE <br /> d <br /> (Please DEQ 7 to 10>SLL,Eness ay <br /> s Er Jae o3apPlica4iorr yuhmittal} <br /> 93 PMECK BOX TO EXPEDII M REQUEST RS UJE T` QCE3fiE�1N 3 BllSil3ESS DAYS �� a �. <br /> rfl DATE <br /> SIGNATURIE= OF APPLICANT <br /> FiLh ACIUKIII 3 <br /> D Uq r, <br /> 2 �a ' <br /> 1 <br /> Z `n^ <br /> ENVIRONMENTAL HEALTH DIVISlO FILES <br /> ❑ HOUSING ABATEMENT <br /> TANK{LIST]CLEANUP SITE(LOP) NT ❑ SOLID WASTE FACILITY <br /> OTHER <br /> CLEANUP <br /> ❑ 5oUn WASTE VEHICLE <br /> OTHER CLEANUU P 51T5(NON-LOP) ❑ FOOD FACI)_l`t'Y Q DAIRY <br /> X UNDERGROUND TANK(MONIYORINWRO40VALl ❑ IDOG KE=NNEL ooLIS ❑ DAG TREATIAENT PLANT <br /> 8C HAZARLIOIIS WASTE GENERATOR 0 MOTEL0CHICKHOTEL K RANCH p pUIti1PERTRuCYJYARDICMEM 7Q6.ETS <br /> M TIERED PE=Re4iTYEI3 FACILITY E7 <br /> El pOOLfSPA ❑ LAND IISt=AAPL.JCATEd1+E SITf^_S <br /> ❑ TA•ITOGIBODY PEiRCING ❑ PUBLIC;WATER SYSTEM ❑ OTHER(PLI I=SPECIFY ABOVE) <br /> 0 MEDICAL WASTE FACH-" <br /> 1. List up to ten addresses in the space above. Sefact the type(s) at files from the list alcove by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to (2o9)464-0735 or mail 4 the <br /> address inclic t flava.: <br /> 2. EHD will notify the applicant it any E1fD files exist. An appointment for review will be confirmed <br /> approximately five buSlnOSS days but no later than tart(10) days iter receipt <br /> should be sched dfiies <br /> will be held for a maxirltium of fvQ business days for review. App <br /> accurdingly. <br /> 3. A file that is actively being worked on by El-iD staff may not be immediately available for review. Anew <br /> application may be submitted when'the file is available. <br /> d. Any iiia not returned in the same condition as released will be ireofganized by EHD staff at th 'e review. <br /> of the applicant. Future file reviews by the same applicant may require a $78.00 depas►t prior <br /> 5. 'TENTATIVE appointment dates must be confirmed with EIiD staff. . <br /> 6. Applications received after 3:00 pm will be processed the next business day <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED pHONE FAX INITIALS <br /> 4 <br /> REVIEW DATE <br /> L- <br /> YES NO <br /> gy{ p0 a 01/6'91 <br />