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C <br /> DATE REr,E1VED <br /> BER/ <br /> SAN J'OAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 7T WEBER AVENUE, THl P-F-LGCI •'` ' r <br /> }. STOCKTON CA 952021; r #Z <br /> (209) 468-3420 <br /> LIC RECORDS RELEASE APPLICATION <br /> APPLICANT Q pGLi eL BUSINESS/AGENCY <br /> ADDRESS <br /> PHONE FA-C�SI-MILE MAY 2 8 2002 <br /> TENTATIVE'APPOINTMENT DATE, n!f O Z TIME jQ, A-E,VIROWENT HEALTH <br /> (Please give 7 0 10 mess s fro to of licatlon,,,su mittal) PERMIT/SERVICES <br /> CHECK BOX TO EXPEDITE REQUES -$87.0 FEE EQUEST PROCESSEI�IN NES AYS <br /> SIGNATURE OF APPLICANT o. 25,C DATE O <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> i <br /> A'2 <br /> • J In d <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT W SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PEIRCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 7. 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 type MUST be selected. Fax to (209)464-0138 or mail to 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. 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 condition 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 $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 business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br />