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FRO Geo-Phase Environmental FAX NO. 2095690295 Oc. 24 2004 12:19PM P2 <br /> irHD LOG NUMBER <br /> 0�7�i scElvEt� F w AN JOA UIN COUNTY <br /> >� ® NTAL E Ta DEPARTMENT or A <br /> .: <br /> 4 ZQ00 304 E Weber Ave P Floor Stockton,CA 95205 wwwal <br /> (209) ¢8-3420 Fax'. (209)464-0138 Web:WWW.00.Sk1-joaquin,ca.us/ehd <br /> LICRECORDS RELEASE APPLICATION <br /> PUB <br /> ,,_SUSINESSWENCY: <br /> APPLICANT: 5 T;t <br /> t/ <br /> ADDRESS: <br /> FACSIMILE: <br /> PHONE: 7 <br /> TENTATivE' Time: <br /> POINTMENT DATE: --—�— « <br /> (please allow 10 business days from date of application submittal) ,. <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT T Department Use 0 IY <br /> UNIT (� <br /> Fit ADDRESS _\ <br /> x ❑ Unit 1 <br /> \ti 2. stmt <br /> s� r <br /> a. 3ue� <br /> 1k> Unit 3 <br /> s. sveet '� . <br /> a. Street Unit 4 <br /> G <br /> e. street rh " Q Unit 5 <br /> e. street <br /> moo: <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> O SOLID WASTE FACILITY <br /> x UNDERGROUND TANK(LIST)CI-F- SITE(LOP) FO'�IFACiNG�LITY MENT p SOLID WASTE VEHICLE <br /> Cl OTHER CLEANUP SITE(NON-1-0P) f"" 7 r <br /> /+� UNDERGROUND TANK(MpNrrORINGIREMOVAL) ❑ DOG KENNEL a PKG TREATM€ttT LANT <br /> ❑ HAZARDOUS WASTE GENERATOR A CHICKEN RANCH 1LETS <br /> ❑ MOTV-LIHOTEI ❑ PUMP@R {3UCKlYAftDlCH <br /> b TIERED PERMrMED FACILIZYL►sE3LAND USEf P 1I SITES <br /> [3 POOPA <br /> M TATTOOIBODY PIERCING U OTHER Lt (PLEASE SPECIF`O_ <br /> d MEDICAL WASTE FACILITY <br /> 1. <br /> List up to ten addresses in the space above. Select the types)of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to 209 464-0135 or mail to the <br /> address indicated above. ointment for review will be confirmed <br /> 2, <br /> EH D will notify the applicant if any END files exist. An app <br /> approximately five business days but no later than ten(1(l)days after should application. <br /> scheduledtion. e flies <br /> will be held for a maximum of five bl�siness days for review. Appointments <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. by at the expense <br /> 4. Any file not returned in the Sam e conditionbyhe as released aantl may be re uire a$93.0 Hdeposit prior to eview. <br /> of the applicant. Future file rev must <br /> by the same applicant y q <br /> 5 TENTATIVE appointment dates must be confirmed with END staff• <br /> processed the next business day. <br /> 6. Applications received after 3:00 pm will be <br /> APPiDINTMENT.DATE ..•_J.. .'.:..' TIME <br /> FAX <br /> DATE CONFIRMED . <br /> REVIEWED YES N® �viE DATA <br /> EMI)48-G2-CM - <br /> 8/Ef20G9 ' <br />