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_Sep 02 05 09: 34a pi i 408- 3-1224 p. 1 <br /> 1/ <br /> rE <br /> vUEHD LOG NUMBER <br /> SAN JoAQunv CotnvTx <br /> SEP - 2 2005 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br /> ENVIRONMENT HRVW68-3420 Fax: (209) 464-0138 Web: www.co,san-joaquin.ca.us/ehd 1915Z <br /> PERMIT/SERVICES <br /> PUB/LIICRECORDS RELEASE APPLICATION <br /> APPLICANT: I BUSIINESS/AGENCY: <br /> 1 <br /> ADDRESS: ��D� �o M lr11 G�✓L�O C/dr 9—f <br /> PHONE: t/1S I G"I o��0� FACSIMILE: <br /> TENTATIVE`APPOINTMENT DATE: Time: V( <br /> (Please allow 10 business days from date of application submittal) COOK <br /> CHECK BOX TO EXPEDITE REQUEST-$93 00 EE—REQUEST PROCESSED IN 3 BUSINESS DAYS D <br /> SIGNATURE OF APPLICANT 1f'""1`'� " "&°�Oo p r ` DATE 1' !' -O J (; -; <br /> Department Use Only <br /> FILE ADDRESS UNIT 0 <br /> \j1 ' Street2. Street Cit Unit 1 <br /> city <br /> S <br /> 3. Street &Sf tKg- / El Unit 2 O� 1 <br /> 1. Street ► �.1�_ Ci <br /> 5, seeet city <br /> Street 3 Gt cityCl. Unit 3 <br /> T. Street /-- cityUnit 4 <br /> a <br /> e. street S <br /> 9. Stieel �/I <br /> 2Na1" _v5e4 'Y0 Q Il El Unit rJ <br /> 10. Street G <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> , 'UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> -OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONrrORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ,,[?-'HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT 91 <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br /> ❑ TAT700/BODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail to the <br /> address indicated above. <br /> 2. EHD 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 new <br /> application may be submitted when the file is available. <br /> 4. Any fele 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 DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 08-02-0GG <br /> 81812003 <br />