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04/30/2003 09:42 FAX 209 9480621 <br /> - Q)002 001 <br /> OATE RECFJV,ED <br /> ,'. _!I11\ [,/ r_,r '• EHDIIYiNUMBER <br /> � <br /> ��AN JOA-C�U1N COUNTYPUBLIC HEALTH SEt_VJICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> APR 3 0 2003 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> cNVEHEAL (209)468-3420 <br /> r✓}/. r,,+ ;r�F ��l(F'WU13 LIC RECORDS RELEASE APPLICATION <br /> APPLICANT- �+ ��� /r'I..•' � BUSINESSIAGENCY Ac - e%1 •- <br /> ADDRESS e't-1�� "�S r'4 /'�7yr,L!-e S-A- <br /> PHONE ���- ��yS FACSIMILE 14 <br /> TENTATIVE*APPOINTMENT DATE /%/� 3 TIME <br /> (Please give 7 to 10 business days from date of application submittal) <br /> C1 CHECK BOX TO EXPEDITE REQUEST-$67.00 FEE-REQUEST PROCESSED IN 3 BUSINE155 13AYS 1 I //p <br /> SIGNATURE OF APPLICANT .�J iv .��� DAATfE6 <br /> FILE ADORESS THUS SIDU EIiD S i AFF USE ONLY —��- <br /> PROGW,M ELEMENTS SEARCH <br /> /876 Cou,+4ry CfvsPIZ <br /> /p Y6Y14-T- <br /> 0G I pvntr, I✓� VL <br /> a 10 3 -I. V, <br /> l � s 1 COV..-1•r �lr..L �(✓ . <br /> lYd 3 ove%+--y Chis -fl I✓4 <br /> C/V6 I..,z -- <br /> 70 97 cr+� Club B.1 <br /> a-7o'Z S C0­N4-r-y C I vb Tj l v L p`I <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> ..91UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT a ILID WA:6TE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILnY � SGUI�WASTE VEHICLE <br /> -XNDERGROUND TANK(MONITORING/REMOVAL) O DOG KENNEL O DAIM' <br /> D HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG•TREATMENT PLANT <br /> O TIERED PERMITTED FACILITY ❑ MoTEL/HOTEL ❑ PUMFERTRUCKIYAROICHEM TOILETS <br /> ❑ TATTOOIBODY PEIRCING ❑ P001.SPA "' ❑ L<,NEI USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY O PUBLIC WATER SYSTEM 0 o-rHI:R(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Select the type(s) of files Pram the list above by checking <br /> the appropriate bOX(es). At least one file type MUST be selected. Fax( e2,, 09) 46d-0738 or r,Iail o 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. Appointrrlerlts should be scheduled <br /> accordingly. <br /> 3. A file that is actively being worked on by EHD staff may not be immediiittbly available for reiriew. Anew <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 EMD 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 busineas day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS _ <br /> REVIEWED YES NO REVIEW DATE ' <br />