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04/07/20 4� 118 AGE STOCKTON .- PAGE 01/01 <br /> III LOGNU..sF; <br /> rr.. ..QUIN COUNTYPUBLIC HEALTH AICES <br /> APR fl 7 2pp3 NVIRONMENTAL HEALTH DIVISION <br /> 304 FAST WEBER AVENUE,THIRD FLOOR <br /> ENVIRONMENT HEALTH STOCKTON CA 95202 <br /> PERMIT/SERV iZOg)468-3420 _ <br /> �€�LIC RECORDS RELEASE APPLICATION' <br /> 00, <br /> APPLICANT SUSINESSJAGENCY � � nu�r�� _ <br /> ADDRESS <br /> PHONE (X 9&17FAC51a41ELE <br /> T1=NTATIVE•APPOINTMENT DATE' TIME __ +10- 3 )a <br /> (Please give 7 to 10 business days from data t application sUbmiliai) <br /> CHECK BOX TO EXPEDITE RE 4U T-S44.oD FEE- REQUE5T ROCE55E0 IN 3 HUSINtr55 DAYSLo <br /> SIGNATURE OF APPLICANT DATE ` <br /> FILE AI)bRr;SS <br /> r Ue , 77 �. <br /> Q I 71kg. <br /> IF 4, <br /> of to 7 <br /> 7 1 Sr <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOUpl WASTE I-ACILITY <br /> OTHER CLEANUP SIT15(NON-LOP) ❑ FOOD FACILITY Q SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL 17 DAIRY <br /> HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH ❑ PKG TREATMENTPLANT <br /> Q TIERED PERMITTED FACILITY 0 MOTEL HOTEL O PUMI-ER TRUCKIYARDICHEM TOILETS <br /> O TA77001800Y PEIRCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ PVBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Select the type(s)of fries frbrn 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 END files exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ten (10)days after receipt of a.K/plicatlon. The file; <br /> will be held for a maximum of fve.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 now <br /> application may be submitted when the file is available. <br /> d. Any file not returned in the same condition as released will be reorganized by EHP staff at the expense <br /> of the applicant_ Future file reviews by the same applicant may require a S78.001depotom <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff, ` ] ^F 4 : <br /> Alm <br /> 6. Applications received after 3:00 pm will be praY <br /> eessed tho next business rla i T ' <br /> I <br /> CON FIRMED-APPOINTMENT DATE TIME <br /> DATE CONFIRMED _ PHONE FAX INITIAL; <br /> i <br /> REVIEWED YES NO REVIEW DATE <br /> FM 00 14 01105M0 �Y <br />