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T(Mk 5111 VS �ClPM Has" 4's Environmental, Inc 510j6249098 P.1 <br />a III <br />TE RECEIVED EHD LOQ NUMBERI' JAN7 2015A JAUI COUNTY <br />ENVIRONMENTAL HEALTH STET <br />NV18GNMEIVTAL 1868 East Hazelton Avenue, Stockton, CA 95205-6232 <br />ERMIT/SERVI ane: (209) 468-3420 Fax: (208) 464-0138 Web: wwvv.sjgov.or�/ehd <br />so <br />LIC APPLICATION <br />APPLICANT: SAM L®,��� BU SINESS/A®ENCY: &16kL-5 �tjviabAJOAXwA.L,Iot- <br />AgD�DRESqS: 6 5S /1�2TA4 ST16CT- , Swpy,T,�,�yy®12.!a (r t y1 CITYIS®TA®TE/ZIP::/ncl�®Av.LCAjo t. cAqLi bpol <br />PHONE (1): �Q� pI`1p�d�� PHilNG(Z): CSc FJ�a 1^�-l;i FAC 'MILE: (�1®� V��r�6d1 <br />Please allow 10 business days from date of application submittal for the records to be available. <br />Staff will contact you to arrange an appointment date and time to review the requested records. <br />❑ CHECK BOX TO EXPEDITE REQU - $130 FEE (CAS R CHECK ONLY) - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE of APPLICANT_ DATE <br />1 „ List [I Map— Description:- I <br />SperAfio Date Range of Informatlon Requestep: From to <br />. ENVIRONMENTAL HEALTH DEPARTMENTFILES ,--�,.� <br />DEROROUND TANK (UST' CLEANUP SITE (LOP) 2 MEDICAL WASTE FACILITY LTJ LID WASTE FACILITYIVEHICLE <br />41HER CLEANUP SITE (Nom -LOP) ❑ HOU®IN® ABATEMENT LaVASTE TIRE <br />DEROROUND TANK (MONIIORINBIREMOVAL) ❑ FOOD FACILITY ❑ DAIRY <br />BOVEOROUNDTANK E] CHICKEN RANCH( DO® KENNEL ASTEWATERTREATMENT PLANT <br />RDOUS WASTEMAZARDOuS {MATERIALS ❑ MOTEL?HOTEL uMPER TRUcl(IYARDICHRMICALTOILETS <br />FRED PERMITTED FACILITY POOLISPA Ej LAND USE APPLICATION SITES . <br />❑ TATTCOIBCDY PIERCING ❑ COMPLAINTIRtESPONSE RECORDS ❑ OTHER (PLEASE SPECIFY) <br />WELL AND SEPTIC PERMIT RLCORDS ARE AVAILABLE: FOR REVIEW: MOi1IDAY-FP.IDAY 8:00 AM -S: M (EXCLUDINIQ HOLIDAYB) <br />I. List ula to ten aggr.Mftaln the space above. Select fhe type(s) of files from the list above by checking the appropriate <br />box(es). At least one file type MUST be selected. Fax to j ge) 484-01 S8 or mall to the add a Indicated above. Address <br />rangis will not be accepted. Applications received atter 3:0o pm will be processed the next business day. <br />2. For itssl+tance In Identifying the nature and content of EHD records, please contact kMD at the number noted above. <br />3. -The END will notify the applicant 11 any EHD files exist. An appointment for review will be confirmed approximately ton (10) <br />days after recelpt of appiloation. The (Iles will W held for a maximum of five business days for review. Appointments <br />should ba scheduled accordingly. <br />4. Any file not returned In the some condition as released will be reorganized by EHD staff at the expense of the applicant. <br />Futuro file reA reR Ery tha cams applicant may require a $130 deposit prior to review. ••*0QXF.R AREA - HD USE ONLY••' <br />ZZI <br />I �t wm <br />Cords provided-by-St�itf'PP r„®mplat"taff-Name: <br />eceived TI Jan. 26.'"2015= 4;54PNFNo-29.5..8% <br />