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LL U i <br /> StIPC COUNTY PUBLIC HEALTH ,!31,,, Jul <br /> ENVIRONMENTAL HEALTH DIVISION .. <br /> • 304 EAST WEBER AVENUE. THIRD FLOOR DEC 1 4 00 ' <br /> STOCKTON S5202 <br /> (209) 468-3-3 4200 <br /> VIRUN1,1E dT IitALTH <br /> LIC RECORDS RELEA/SE] APPLiCATiO cr S }� <br /> APPLICAN C014Io <br /> BUSIHESSIAGENCY L✓LUUQYI rr11r{ 11'S�OV1 U/r U�}/YJ�rI 1.�LYx. <br /> ADDRESS DO J C.CJ/[ SD l Q C CA SOS <br /> PHONE aQ O FACSIMILE a i� <br /> TENTATIVE'APPOINTMENT DATE TIME <br /> (pinasa give 7 to 10 la sines days from date of application submittal) <br /> �1 CHECK BOX TO EXPEDITE RECIUMT-$7 .0 E—RE UEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT e4 DATE Z t( dd <br /> FILE ADDRESS <br /> �F <br /> i7l s <br /> OUUCP, Pa, <br /> tZ3 <br /> 2+�rn <br /> Z`-Sw y atit -5ulodat Pyp� cCroMALHEALTH <br /> i. W <br /> NVIRONMENTHEAL H DIVISION FILES .�- <br /> RQ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> 19 OTHER cLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> If UNDERGROUND TANK(MONITORING1REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HA2ARDOU3 WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PUNT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCKJYARDICHEM TOILETS <br /> ❑ TATTOOlaOOY PEiRCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY G7 PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1, Gist 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 appile"if any EMD 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 far 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 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 /> 5. *TENTATIVE appointment dates must he confirmed with END 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 YES NO REVIEW DATE <br /> EH" 14 OtrvvOo <br />