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_ 2-CIIte-" d v,� xv ; <br /> 133-16-2Q30 09�13RM FRol ES <br /> UIN ~a <br /> S ;` SAN -_ UNTYPUSLIG HEALTH : <br /> ENVIRONMENTAL HEALTH DIVISION <br /> THIR <br /> 304 EAST WEBER <br /> STOCKTON NU ,202 D FLOOR <br /> 0 0 1 (209)46B-3420 <br /> LIRLIC RMORDS RELEASE APPLlCATlON <br /> `� i i',cALTH P <br /> �a7 ax1 <br /> t,� aUSINE651AGENCY -i l <br /> '�APPIJCAN L`Q'��4 w <br /> [•'�'.:,~ �� l YnYV\PJrC.0 <br /> y <br /> ADD RESS <br /> ((.� ✓13� - 00 FACSIMILE .-�::✓. <br /> PHONE QO /17 <br /> a 1 L-Zi of nms <br /> TENTATIVE DAl'e�yy� trel •g lin date of appl"tfon snbmlttall . <br /> (Pyase give 7 l0 16 bt+stn�g deN <br /> �. CHEG BOX T6 L-,FfDtTF REQUE`ST-+r0.00 PI,E-it6f�ESYPROCRSSED IN38U51NE5S DAYS <br /> OATE <br /> SIGNAT RE OF APPLICANT (/y <br /> THIS DE END STAONLY <br /> SIFF USE <br /> PILE ARDRESS PROGRAM ELEMENTS SEARCH <br /> 3S a-� fk 3S- ? <br /> _ -1-„ 3,5.a8 029.G U .✓(i. <br /> - <br /> � 1 r � ~ ss•a� 1� _ . <br /> ENVIRONMENTAL HEALTH DIVISION FILES f= <br /> Q SO TE FACILITY <br /> :�iINDE ROt1ND TANK NST} ABATfCLEANUP SITB.(LOP) O HHOUSIFACa.CTY MF11T d $0L1DWASTEYEHICLt <br /> FOOD <br /> SC(OTHE CLEANUP STTB(NONdAP) L-+ DOG KMtNEL 6 DAIRY <br /> $1' UNDFA(3ROUNb TANK(MONrrOR1NGMDiOVALl C1 CHICON RANCH ❑ PKt3 Tp.EATMPNT PLAt'rr <br /> HAZAI�DOU3 WASTL GENEnATOR p MOTELIKOTEL El PUMPER T AppWYARL7/CHEM TO4LETS <br /> TIERE PERMITTED FACILITY ❑ T�OIJSPA ❑ LAND USE pppLICATION SITES <br /> n TATT0�TISOOY PEIRCING ❑ PUBLIC WATER$YSTEM ❑ OTHER(PLF1t6&SPECIFY ABOVE) <br /> ❑ MEDICAL WASTE FACILIT't <br /> � sof files from the list above bmchecking <br /> �. List up to ton addresses In the space above. Select the type(s) <br /> the appropriate box(es). At least one file type MUSY,be seceded. Fa 209 <br /> address in FAte ave- intmerst for review will be Confirmed <br /> 2. EHD will notify the applicant if any EHD flies eXIst. An 6ppo s offer receipt of application. The Cites <br /> approximately rive bueinass days;but no later than ten(10)day <br /> will be held For a maximurn of five business days for review. Appointments should be scheduled <br /> accordingly, y y available for review. A new <br /> 3. A file that is active! being worked on by EHD staff may not be Immediately <br /> application may be submitted when the file is available. <br /> 4. of fiiQ not <br /> ned in the Future tiler reviews by the same 613111 eanitlbe may require a$SY00 depoait panized rior to EHD staff at the evf aw. <br /> 5, "TENTATIVE appointment dates must be confirmed with SHO staff. <br /> B- Applications received after 3:00 pm will be processed the next business day. <br /> CON <br /> RRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED <br /> PHONE FAX INITIALS <br /> REVIEVYED YES NQ REVIEW PATE <br /> 9D 14 7 TOTPL P.02 <br />