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AUG-23-2004 15:51 CF"n9R EARTH TECH 209 532 0773 P.01/0: <br /> DATE RECEIVE? <br /> R SAN JoAQ�N COUNTY EHD LOG NUI <br /> ENVIRONMENTAL$FjAT_.TH DEPARTMENT <br /> AVG 3 2pfl4 304 E Weber Ave 3'd Floor Stockton, CA 95205 <br /> ? 468-3420 Fax: (209) 464-0138 Web: www,co.sau-joaqu n,ca us/ehd <br /> �NVIR� IT SERVICES <br /> oFRM . PU"BLYC RECORDS RELEASE APPLICATION <br /> A tom. .� <br /> APPLICANT: � .,L�A�-r��eE�BUSINESSIAGENCY: <br /> ADDRESS:LF <br /> PHONE FACSIMILE 7 73 <br /> TENTATIVE'APPOINTMENT ogTF: Tlme: ' <br /> (Please allow 10 business days from date of applitatlon submittal) <br /> Q CHECK BOX To EXPEDITE RE VEST-;93,00 REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE; OF APPLICANT DATE . 6 <br /> Denartment Use Only <br /> / FILE ADDRESS UNIT <br /> is- LLQ d ia57 F{". C © Unit 1 <br /> ✓ 2 Street344 <br /> ( t <br /> 1//1/' 3. strep 00 L Mbe city UnR 2 <br /> 411 ,. qMIl K_ C.!' ZCL <br /> V s. suit 6 My I t <br /> - Unit 3 <br /> s. Sv.e1 a � <br /> f 7. S1.1 IPR aly U 57 F5 Unit 4 <br /> e szrMat 10 L cm <br /> a. st,.°` 1.Ik Ej Unit 5 <br /> 10. bueet E• A , � D -.nA <br /> r <br /> ENVIRONMENTAL HEALTH DEP T FI>_Ej�� X un 4 " <br /> UNDERGROUND TANK(UST)CLEANUP SITE(I-op) 4 HOUSING ABATEMENT 4Pr $OUD WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) " L1 FOOD FACILITY soLlb WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL, d DAIRY <br /> HAZARDOUS WASTE GENERATOR C CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> �Y TIERED PERMITTED FACLJTY ❑ MOTELMOTEL d PUMPER TRUGKIYARDICHEM 701LI=TS <br /> Q TATTOOIBODY PIERCING Q POOLISPA LAND USE APPUGATION 51 LE i <br /> t3 MEDICAL WASTE FACILITY 0 O1HER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by aheckin <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. E;HU will notify the applicant if any EHD files 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 ne <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 expens <br /> of the applicant_ Future file reviews by the same applicant may require a$93.00 deposit prior to revie' <br /> 5. TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3.00 prn will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE= CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> TOTAL P.O: <br /> �`-� 6 C <br />