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DATE REr,EIVED <br /> BER/ <br /> SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EA T WEBER AVENUE, THIP .FL©OR,- <br /> ^t STOCKTON CA 95202 d ' 21Zia <br /> (209)46$-3420 <br /> LIC RECORDS RELEASE APPLICATION <br /> APPLICANTGL ' �i_�Z BUSINESS/AGENCY t <br /> ADDRESSZIA <br /> PHONE oL1� FA—CSIMILE OS? MAY 2 8 2002 <br /> TENTATIVE*APPOINTMENT DATE n e-- O Z .TIME _ e? Thi ARUVIROWENT HEALTH <br /> (Please give 7 o 10 iness s fro to of I' Non su mittal) PERMIT/SERVICES <br /> CHECK BOX TO EXPEDITE REQESFEE EQUEST PROCESSEITIN �NE$ AYS <br /> SIGNATURE OF APPLICANT DATE D <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> 5.�- <br /> r <br /> /l/ # <br /> 1n a <br /> 5' 3S21, <br /> r�cc <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSING ABATEMENT SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONrrORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY . <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PEIRCING ❑ POOOSPA ❑ LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY ❑ PUBUC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY 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 mail 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 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 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 reviews by the same applicant may require a$87.00 deposit prior to review. <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 /> DATE CONFIRMED PHONE FAX INITIALS <br />