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SAN JOA,411N COUNTY PUB L__1CHEAL_TH.SE,.,/iiC L 100 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEDERAVENUE.THIRD FLOORDEC 1 <br /> STOCKTON CA 952112 <br /> u' (209)468-3420 �ry <br /> LIC RECORDS RELEASE APPLiCATIO V"'NLME JT HEALTH <br /> 4 <br /> APPLICAN , BUSINESSIAGF-NCY Q�luanclenrl <br /> ADDRESS az�tUO .� C.(J/�SD Q C /t/7 SaDS� <br /> PHONEIlk 1,9FACSIMILE <br /> TENTATIVE'APPOINTMENT DATE TIME <br /> (Please give T to 10 business days trom dais of appllcatlan submittal) <br /> IFP COn <br /> HECK BOX TO EXPEDITE REOUFSf-07.00 <br /> UEST PROCESSED IN 3 6U$ME55 DAYS <br /> SIGNATURE OF APPLICANT �.' q DATE Z t( 170 <br /> FILE ADDRESS <br /> \I <br /> � O <br /> ( ormL <br /> (fl n <br /> �-YVAQO'rtaK1 _btA�B,t NVIRO MEN A HEAL H DIVISION FILES � ( <br /> l rl EF i f' 3 {- •�► <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> 1%1 OTHER CIF.ANUP SITE(NON-LOP) ❑ FOOD FACILITY D SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL O DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL 0 PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOMODY PEiRCING ❑ POOLISPA © LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY O PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses In the space above. Select the type(s) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to f209) 464-013$ or mail to the <br /> address indicated above. <br /> 2. EHD will notify the appile"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. Afile that Is actively being worked on by EHD staff may not be immediately available for review. A new <br /> appllcaDon may be Submitted When the file is avallable. <br /> 4. Any file not returned In the same conditjon 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 /> S. `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 /> REVIEWED YIES NO REVIEW DATE <br /> EM OC Ia C110Y00 <br />