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SA)� JC3�rN COUNTYPUBLIC HEALTi i S IC ���� `� 1. 11 <br /> L IVIRONMENTAL HEALTH DIVISWIV 1-f <br /> 304 FAST WFEER AVENUE,THIRD FLOOR DEC 14 100 <br /> STOCKTON CA 95201 <br /> Y (209)468-3420 VIRONMENT HEALTH <br /> „ itL1C REG©RDS RELEASE APPL1CATi0 F S <br /> -- �� Q�uaxcer� �Pc��rYJn1�111.Tix. <br /> APPLICANT BUSIHESSIAGENCY f � <br /> ADDRESS `7VQ S J��] Iwnl�/S�D 4 C CAI 6's— <br /> � �/G � —///19 <br /> PHONE 9D9) 7 LY I !(lO7lJ FACSIMILE <br /> TENTATIVE"AP POINTUENT DATETIME <br /> (Ploase give T to 10 boa{nesa days from date of apPllcatlon submittal) <br /> � 00 <br /> �lI CHECK BOX TO EXPEDITE REWW'SrE-O9 E-RE UEST PROCESSED IN 3 BUSINESS DAYS <br /> NN1I � f� s Q DATE <br /> SIGNATURE OF APPLICANTtY <br /> FILE ADDRESS <br /> �q�' IrP OGe� \ �51•rYE `^ '� - I - 1 11 �— <br /> ID <br /> t1I I rlOUNA <br /> t oY i i <br /> rtGWW1�Y ttAS� YI �f l I 1 l <br /> -Srrpo�FAv<t —s>,t4�a:c� PaO��NVIRONMENTAL HEAL H DIVISION FILES <br /> ❑ HOUSING ABATEMENT O SOLID WASTE FACILITY <br /> 0 OTHERC CLEANUP <br /> TANK(UST)CLEANUP SITE(LOP) ❑ FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> >$T OTHER CLEANUP SITE(NON-LOP) <br /> f5( UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL O DAIRY <br /> ❑ CHICKEN RANCH ❑ PKC'TREATMENT PLANT <br /> ❑ HAZARDOUS WASTE GENERATOR 13 MOYELlHOTEL ❑ PUMPER TRUCKJYARDICHEM TOILETS <br /> ❑ TIERED PERMITTED fACIUTY ❑ POOLISPA D LAND USE APPLICATION SITES <br /> ❑ TATTOO/BODY PEIRCING O PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> ❑ MEDICAL WASTE FACILITY <br /> 1. List Up to ten addresses In the space above. Select the type(s) of files from the list above by checking <br /> the appropriate box(es). At least one file typo MUST be salected. Fax to (2091 464-013$ r mail to the <br /> o <br /> address indicated above. <br /> 2. EMD will notify the applleant if any B}iD files exist. An appointment for review will be confirmed <br /> approximately five business days but no.later than ten (10)days after <br /> re ei thou d be scltiedThe files <br /> will be held for a maximum of five business days for review. App <br /> accordingly. <br /> 3, A file that Is actively being worked on by EHD staff may not be Immediately available far review. new <br /> applicatlon may be submitted when the file is available. <br /> 4- Any file not returned In the same condition as released will <br /> illrbea reorganizire ed$8Yo Hstaff deposit prior expense <br /> of the applicant. Future file reviews by the samo applicantY 'fl' <br /> 5- 'TENT ATIVE appointment dates must he confirmed with EHD staff. <br /> 6- Applications received after 3:00 pm will be processed the next business day. <br /> TIME <br /> CONFIRMED APPOINTMENT DATE <br /> 1 PATE CONFIRMED <br /> PHONE FAX INITIALS <br /> REVIEW DATE <br /> REVIEWED YES NO <br /> EN 4n I� Otrvaoa <br />