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• EHO I.OG NUMBER <br /> DATE RecElvea SAN JOAQ'UIN CouNTX � <br /> E NvIRoNlviml`1TAL H,EAI..'rH b;EFA.R.TBVNT <br /> 304 r Weber Ave 3`d Floor Stockton, CA 95205 <br /> RECEM -3420 Fax: (209) 464-0138 Web: www.cc.san-joaquin.ca.us/ct. <br /> _ _ ��UJyyPUBLIC CORDS RELEASE APPLICATION <br /> JUE <br /> APPLICAY <br /> �T l% �J BUSINESS(AGENCY: [� �i l/ 1J °' •- <br /> VIR <br /> ADD <br /> PHONE: �" in i FACSIMILE: / � 1_' <br /> TENTATIVE"APPOINTMENT DATE:'\yLLa <br /> (Please allow 10 busk abs days from date of application submittal) <br /> u CHECIt BOX TO EXPEDITE REQUEST•S9933.00 FEE—REQUEST <br /> PROCESSED IN 3 SUS''NESS DAYS <br /> SIGNATURE OF APPLICANT 1''t'If'( y'"v" OA T E 7 ft p <br /> Ii Deoar"wit Use Only <br /> UNIT <br /> FILE ADDRESS <br /> 1. an�r <br /> /� CKmC3 — t (] Unit <br /> _. Fpnel <br /> c, Q Un)t 2 <br /> 4. Fln�r• i .. - y <br /> G. 0YLM1 <br /> UnR�i <br /> el <br /> ww'. <br /> Unit 5 <br /> 10, M et <br /> _/ ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 07 UNDERGROUND TANK(USTI CLEANUP SITE tLOP) ❑ HOUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> ❑ FOOD FACILITY ❑ SOLID WASTE VFHICLP <br /> [!?(OTHER CLEANUP TANK <br /> (NON-LOP) ❑ DAIRY <br /> /UNOERGROUNb TANK(PgONITORINGIREMOVAL) 0 DOG KENNEL <br /> 6jHAZARDOUS WASTE GENERATOR ❑ CHICKENMOTELrH RANCH ❑ PKC TREATMENT PLANT <br /> lYY TIERED PERMI TED FACILITY 10 MOTELIHOYEL 0 P NE)US 7RUCKiCATION SIM TOILETS <br /> D TATTOOIBODY PIERCING O OTHER(A ❑ LANE)USE APPLICATION SITES <br /> O MEDICAL WASTE FACILITY 13 OTHER(PLEASE SPECIFY) <br /> 1. List up to tan 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 120gt 464-0138 Dr 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 'flies <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 appiicant. Future file reviews by the same applicant may require a$93.Do deposit prior to review. <br /> 5. `TENTATIVE appointmant dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMEE) AENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEN/ED YES NO REVIEW DATE <br /> aRr100] <br />