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1 C 'J <br /> SAN JO �U41N COUNrfPUBLIC HEALTH .S'I�1IC. li= <br /> ENVIRONMENTAL HEALTH DIVISION -R <br /> J 304 EAST WEBER AVENUE,THIRD FLOOR DEC <br /> STOCKTON CA 95202 <br /> (los)468-3420 VIRONME!T HEALTH <br /> LIC RECORDS RELEASE APPLIC/ATiOFt� <br /> APPIJCAN �7 / 7 / BUSINESSIAGENCY L(I�UQYIGL°Lr (?Pp�'1(Jl!'D�'}119P/J (C11.Z1',r. <br /> ADDRESS V� U/J�I I s.7 Q C CA 5�qdSa <br /> PHONE �NQ _ !J FACSIMILE a G <br /> TENTATIVE'APPOINTMENT DATE TIME <br /> (Plnnse give 7 to ie bualnam days from date DI applicattan submittal) �- <br /> D� <br /> Ep CHECK BOX TO EXPEDITE REQUEST.$7 A E-RE UEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT y Q DATE (I Dn <br /> FILE ADDRESS <br /> 1�F <br /> O <br /> � it 111 <br /> l or <br /> �1 33 E. 9)okS & Vit /.. <br /> PvvME HEALTH i. W <br /> Q K:NVIRONMCNTAL <br /> DIVISION FILES <br /> K UNDERGROUND TANK{UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> W OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> kr UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> In HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELMOTEL Q PUMPERTRUCKP(ARDICHEM TOILETS <br /> ❑ TATTOO/BODY PEiRCING ❑ POOL/sPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY O PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1, list up to ten addresses In the space above. Select the type(s) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected, Fax to(209) 454-013$ 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 fora maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3. A Fite 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 avallable. <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 he 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 PRONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br />