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_ <br /> 4�..,,., . <br /> SA� N- : iQUIN COUNNTYPUBLIC. HEALTH +'WiGES <br /> NVIRONMENTAL HEALTH DIVISI <br /> 304 EAST WE13ER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> (209)458-3420 <br /> " LIC RECORDS RSL ASE APPLICATION <br /> r�33 r <br /> ApPLICAN SGSfNE551AGENCY aLijanL�'O� (WO&U-L,2 �f., tr. <br /> So�JtJ�{��� <br /> PHONE �0 — FACSIhtiLE ._ 11 d <br /> TENTATIVE*APYC:EhITDAENF DATE <br /> �fJv� r TIMe -a' 00 <br />} (Pleas&glove 7 to i0 busir+ess days 1 date of application Submittal) <br /> CHECK SOX TO EXPEDIM REQUEST-37 .00 EE—RE 0 ST PROCESSED IN S BtASINESS DAYS <br /> SIGNATURE OF APPLICANT IaATE �r �?,p o C7 <br /> FILE AWRESS <br /> t . <br /> 3535��] <br /> -Z Vk.9- E ` <br /> NTHELTH DIVISIO FltESNVIRONMEALA _ <br /> LINDERGkOUND YANK(UST)CLEANUP SITE(LOP) 17 HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> �Q OTHER CLEANUP SITE(NON-LOP) ❑ FOOD PAC11.17Y ❑ sOUK)WASTE VEHICLE <br /> UNDERr.ROUNDTANK(I OMI-rORINWRENIOVAL,) 0 DOG KENNEL ❑ DAIRY <br /> �{ RA7ARBOUS WASTE GENERATOR 13 CHICKEN RANC14 ❑ £'ICG TREATMENT PLANT <br /> ❑ TIERED YIZR14ITCEpFACIUIT`f C BACTELMOTEL ❑ PUMPER TRUCIUYAIR0JCHEMTOILETS <br /> ❑ T'ATTOciDODY PEIRCING 10 POOLISPA ❑ LAN[]USE APPL-ICA-nON SMS <br /> 4 MEDICAL WASTE FACILOY 0 PUBLIC WATER SYSTEM 13 OTHER(PLEASE 5PEC:FY ABOW <br /> 1. List up to ten addresses in the space above. Select the type($) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(209) 464-038 or mail AP,tho <br /> address indicated above. <br /> 2. END will notify the applicant it any E1JD files exist. An appointment for review will be confirmed <br /> approximately five busln ess days but no later than ten (10) days after receipt of application. The files <br /> will be Feld for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. 11 <br /> 3. A file that Is actively being worked on by I`HD staff may not be immediately available for review. Anew <br /> application may be submitted whan'the file is ayailabie. <br /> 4. Any file not returned in the same condition as released-will be reorganized by EHD staff at the expanse <br /> i of the applicant. Future file reviews by the same applicant may require a$78,04 deposit prior to review. <br /> a. 'TENTATIVE appointment dates must be confirmed with 0-1.0 staff. <br /> 6. Applications received after 3:00 pm will be processed the next business clay, <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br />