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,e I HD LOG NUM135R <br /> DATE RECEIVED SAN JOAQUIN GOUN17Y ;t <br /> � ` ENVIRONMENTAL HEALTH DEPARTMENTBE ; <br /> E gob l=ast Main St. Stockton, CA 95202-3029 s 'ov.orgjehd <br /> �A1S 1 �1Z <br /> Telephone: (209) 468-3420 Fax: (209)4-64-0138 Web:vvvvw• 19 <br /> LIC RECORDS RELEASE APpLICAYION <br /> F NTALHE1111r,.At-�M pI,1Qii <br /> nv n rn n0 <br /> i pE�tldilTfS 13USINEssIAGENCY: <br /> r Id <br /> APPLICANT- 1 CITY/STATcE �r <br /> '� FACSIMILE: <br /> irk.. � : : <br /> ADDRESS: 33 5`� W PHONE(2)= <br /> $ 13, r �K Time: <br /> _ PHONE(i)- must be confirmed) <br /> £ TFNTATlVE"AP date from date of appiicatien submittal-`Tsnta6va only:- iN 3 BU$INF DAY5 <br /> (Plea59 allow 10 business day OR CHEGK ONLY)-REQUEST ppbGES5Fp i � <br /> �]CHECK I3CX TO EXPEDITE RF-QUPST 51 FEE H Ip DATE <br /> SIGNATURE OF APPLICANT Vp J. <br /> List E]Map—Description: <br /> 44 Electronic Information: E] E}i°USE fl1yRY <br /> FILE ADDRESS ❑Unit 1 <br /> City i <br /> Street# Street Name <br /> L. <br /> 2 <br /> Unit 3 <br /> 3. r <br /> 4. <br /> f <br /> 6. 1 ❑Unit 5 <br /> 7. <br /> $ Tilt <br /> to <br /> SPecifc Date Ranee of Infarmation Requested: Frortz $gL10 WASTE FACILITYl11EHIC1 E <br /> ENVIRONMENTAL I-IEALTI 1 DEPA TMf=NT—FILES <br /> 0 Houswr,ABATEMENT ]WASTETIRE <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑FOOD FACILITY IRYTHER CLEANUP SITE(NON'LOP) El Doo KENNEL JWDA <br /> ASTEWATPRTREATMENT PLANT <br /> NDERGROUND TANK(MONITORING1RENiOVAL) �CHICKEN RANCH PUMPER TItUCK1YAR4IC1{EMICAL TOILETS <br /> A7ARpOUS WASTE GfNERATOR ❑MOTELIHOTEL ❑LAND Use APPLICATION SITES <br /> R TIERED PERIfiTTEfl FACILITY ❑p0011SPA <br /> TATT001BODY PIERCING ❑OTHER(PLEASE SPECIFY) EXCLUDING HOLIDAYS] <br /> MEDICAL WASTE FACILITY <br /> Wel--AND SEPTIC PERMIT RECORDS ARE AVAILABLE FDR Rt V18W: MOt3ilAY-FRIDAY 8:04 AM-5:OUPM( ro riate <br /> 1. List up to ten addresto 2091 4 4 <br /> es in the space above. Select tha tyPe(s)of files frorrt`khe 4ist'above by checking the app P <br /> box(es). At least one fila type MUST <br /> b oval ass stance with#ilea dresses,contact the EHD sApplicationsbreceiv received <br /> ranges will not be accepted-for <br /> add100 pm wili be Processed the next business day. <br /> be confirmed 2. Th®END will notify the applicant if a files will be held for a maximHD files exist. An tum of five busient for review n slsl days for rev ewp n�t0 Appointment <br /> days after receipt of application. Th <br /> should be scheduled aceordingty application be <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review- Anew app May <br /> submitted when the fila is available. lioant, <br /> ¢. Dray lila not returned In the Sam®condition as released will be reorganized by EKD staff at the expense of the app <br /> Future file reviews by the same applicant may require a$1 deposit prior to review. <br /> i END USE ONLY _ <br /> . U71x9114 <br /> EFtI]40-65 <br /> J, <br />