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10/14/2004 17:20 2094671116 AGE STOCKTON `�'� /R/ <br />DATE RECEIVED_ - Y� <br />SAN JOAQUIN COUNT" <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />( 4 304 E Weber Ave 3rd Floor Stockton; CA 95205 <br />oc1 1 j(�T14 468-3420 Fax: (209) 464-0138 Web: www.eo.san joaquin.ca.us/ehd <br />T HEALTH <br />-gVif FS PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: 044 L / 13USINFWAGENCY: alfa <br />ADDRESS: it 7�ryS/IQ UJ OOL S� <br />PHONE: _ 7 / Me /a 4//n #% - <br />PAGE 01/0 <br />EHL) LOG NUMBER <br />Z07(a <br />TENTATIVE* APPOINrMENTDATE:.9Z_Dd.;0419' Tama, "-"4-A- HAdq, <br />(Plaasa allow 10 bualness days from data of application submittal) (Lkk4_ <br />CHECK BOX TO EXPEDITE REQU .00 FEE - REQUE T P OCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OFAPPLICANT DATE <br />Department Use Only <br />CC:f�I <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />OTHER CLEANUP SITE (NON -LOP) <br />DD <br />UNDERGROUND TANK (MONITORINGIREMOVAL) <br />HAZARDOUS WASTE GENERATOR <br />❑ DOG KENNEL <br />❑ TIERED PERMITTED FACILITY <br />❑ CHICKEN RANCH <br />❑ MOTEUHOTEL <br />❑ TATTOO/BODY PIERCING <br />❑ POOL/SPA <br />O OTHER (PLEASE SPECI <br />.m. <br />eRESS <br />(�', <br />- <br />/ <br />�' . <br />�" <br />' <br />0,11 ?NO MUM <br />-- -' S <br />• ten,. <br />. ,MEN <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />UNDERGROUND TANK (MONITORINGIREMOVAL) <br />HAZARDOUS WASTE GENERATOR <br />❑ DOG KENNEL <br />❑ TIERED PERMITTED FACILITY <br />❑ CHICKEN RANCH <br />❑ MOTEUHOTEL <br />❑ TATTOO/BODY PIERCING <br />❑ POOL/SPA <br />MEDICAL WASTE FACILITY <br />O OTHER (PLEASE SPECI <br />I UNIT <br />❑ Unit 1 <br />Unit 2 <br />Unit 3 <br />12re Unit 4 <br />❑ Unit 5 <br />j V40,00, <br />❑ SOLID WASTE FACILITY , �J <br />Cl SOLID WASTE VEHICLE <br />❑ DAIRY <br />0 PKG TREATMENT PLANT <br />❑ PUMPER TRUCK/vARDICHEM TOILETS <br />❑ LAND USE APPLICATION SITES <br />1. List up t0 ten addresses In the space above. Select the type(s) Of flies 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' dicated above. <br />2• EHD Will nottfy, the applicant if any EHD flies 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 $93,00 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 .OAT ..' .. !ftME: . <br />DATE CONFIRMED--------------------- <br />• ' P.HONEph,X�_ <br />3N1 fF)t13 <br />REVtEwED YES NO REVIEW67A7E _ <br />