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ajar 18 04 09:11a sic 3LIC WORKS 468 7 I p•2 EHD LOG NUMBER SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT MAR 1 8 2004 304 E Weber Ave 3`d Floor Stockton, CA 95205 ENVIRONMEiA T R0468-3420Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd PERMMSERAVICES PUBLIC RECORDS RELEASE APPLICATI/ON APPLICANT: e -la tdCG.- L7CX1l ([/I.f BUSINESSIAGENCY:.S" TDAQil1�h Wts-[c7� 1`L�GL3�W� � ADDRESS: �rd 2 t / L .�� PHONE: 7J J %i01 `f FACSIMILE: TENTATIVE* APPOINTMENT DATE: Time: ' G.v (Please allow 10 business days from date of application submittal) C1 CHECK BOX TO EXPEDITE REQUEST . $93.00 FEE —REQUEST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT �1 . a� �r DATE ov ENVIRONMENTAL HEALTH DEPARTMENT FILES C Department Use Only UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT *C SOLID WASTE FACILITY OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNEL X DAIRY HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT Nff TIERED PERMITTED FACILITY ❑ MOTELIHOTEL C3 PUMPER TRUCK/YARDICHEM TOILETS ❑ TATTOOBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. 5. "TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE _ TIME DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE END 48-02-006--_-_- 81812003 FILE DRESS_ 7. Streel� • � G 2. Street /S ( S .:J city 3. SVeet ally 4. SW -t W141 _. a 5. stt�t 3 Loge Tree__".. atll 6. Steeet XeLlp J 11 'tL G T. street a! 8. Stmel _ City _. 9. street CN M �! 10. street c ; -- ENVIRONMENTAL HEALTH DEPARTMENT FILES C Department Use Only UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT *C SOLID WASTE FACILITY OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNEL X DAIRY HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT Nff TIERED PERMITTED FACILITY ❑ MOTELIHOTEL C3 PUMPER TRUCK/YARDICHEM TOILETS ❑ TATTOOBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail to the address indicated above. 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed approximately five business days but no later than ten (10) days after receipt of application. The files will be held for a maximum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new application may be submitted when the file is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expense of the applicant. Future file reviews by the same applicant may require a $93.00 deposit prior to review. 5. "TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE _ TIME DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE END 48-02-006--_-_- 81812003