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DATE FtEi.E1YaU <br />FjfA lCc 'u�ME� <br />SAN JQ LJlN COUNTYPUSLIC .HI-ALTHi VICES <br />(� ENVIRONMENTAL HEALTH DIVISION <br />J 304 EAST WESER AVENUE, THIRD FLOOR <br />STOCKTON CA 9520.2 <br />[ (203) 468-342D. �(1 <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPi 1CAlUT M Awnt _ tet .__ SUSIXES AGENCY CAV, s r 1~w* <br />ADDRESS <br />PHONE �f <br />TENTATIVE' APPOINTMENT DATE . - _ TImr;z <br />(Please give?` to 10 busine— days from date of apprication 3abnuttal) <br />ET--Car-CK BOX TO EXPEDITE REQUEST - $37.00 FFA R QUEST kR aS, 3 IN , -,3 BUSINESS DAYS <br />SIGNATURE OF A13PLICANT <br />DATIE <br />MIS SIDE EiiV STAFFIJgJ; ONLI <br />PR36It" EJ-EMENTS SEARCH <br />ENVIRONMENTAL HEALTH DIVISION FEES <br />Z4lNDERGROUND TANK JUST) CLEANUP SITE CLOP) ❑ Ii+DWMG ABATEMENT ❑ SOLID WASTY; FACILITY <br />Gr -OTHER CLEANUP srfE (l oN4.OP) C FOOD FACILITY 13 SOLiM WAST'I=VEACLI <br />Q' 1}115 RGEZUllND TANK {IrA47NII0RINC D 15 311AL} R E QC, IQ~1iNF1_ CRY <br />E' HAZARDOUS WASTE GENERATOR PI"ICHICKEN RANCH ❑ PK(; -TREATMENT PLANT <br />❑ TIERED PERMn -MIM PAGILIT[ ❑ MaTFJJH IELC3 PUNP R TRVCKJYAi 0=1EM TQRJ�TS <br />❑ TATTC iODY PEIRCiNG Q PobLISPA -- - ` ❑ LAND USE APPLICJlTIDN SITES <br />NrMEWCAL WASTE FACILITY 0 PURL C WATER SYSTEM Li 4rhf.ER (PLEASE 3FECIFYABOVE-) <br />1- List up to ten addres.sss In the spaco above. Select the type(s) of files from the list above by checking <br />the approprlalte box("). At least one file type MUST be selected. Fax for (202146,4-0138 or marl to the <br />address LAA ed abcxv - - <br />2. EHD will notify the applicant If any EHD ides exist. An appointment for review will be confirmed <br />approximately five business days but no later than tan (10) days after receipt of applicabon. The files <br />will be held for a maximum of five business days for review. Appointmants should be scheduled <br />acc�ndingty. <br />3. A fife that is actively being warked on by EHD staff may riot be immediately available for review. A new <br />application may be submitted when the fila Is available. <br />4. Any file not returned in the same condition as rele=gd will be reorganl;wd by EHD staff at the expense <br />of the applicAnt Future file reviews by the :name applicant may requim a 587.00 deposit prior to review. <br />5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br />3- Appliestions received after 3:00 pm will be processed the next business clay. <br />CCN FIRMED ApaInITNIErrT DATE -- _ TIME - - <br />]ATE CONFIRMED RHONE FAX INITIALS <br />