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05/25/2005 14:11. FAX 209 94806 _ 121 002 <br /> DATE RECEIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> ppaa <br /> 2'104 E Weber Ave 3`c Floor Stockton, CA 95205 � 7 794 <br /> 2U05 h�l�49P-510-Fax: (209) 464-0138 Web:vrww.co.san-Joaquin ca-us/ a <br /> SA� � COUNTY <br /> NIROMNE <br /> IC RECORDS RELEASE APPLICATION <br /> ht�AAPPLICANT: ' (O 10 6&?' J BUSINESSIAGENCY: 1\ Q1N�G t <br /> ADDRESS: / as 7A, M le- <br /> PHONE: clog "_gyg —I.J�J� Fi�,�3D_FACSIMILE: Gs2O� 9�f$� o(o a ( _ <br /> TENTATIVE*APPOINTMENT DATE: S-- Tlme: poo, <br /> ' (Please allow 10 b da om dot f application submitral) !t1t: <br /> CHECK BOX TO EXPEDfrE REQUEST-597.00 FEE-.RE/QUEE�ST�PROCESS ED IN]BUSINESS DAYS <br /> (SIGNATURE OF APPLICANT �/ tr /'�` - DATE � a .16� <br /> OeaaaV t Use Odd <br /> FILE ADDRESS UNIT <br /> y I. area r7ga Al C41, rN,a S'f" G -+o p ' Unit 1 <br /> \AS T_ 1 'M 2. s 93rs N ! iWk G <br /> a. earWiftinS.ockiwl lea c5±9e Unit 2 <br /> .. s <br /> a4y �(Jnit 3 <br /> ,. sera nit 4 1 <br /> a sv�L <br /> s, svR u <br /> rCo] nit 5 <br /> ENVIRONMENTAL HEALTH DEPARTLo <br /> Rift FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT NL SOLID WASTE FACILrrY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY P SOLID WASTE VEHICLE <br /> ID UNDERGROUND TANK(MONITORINOMMOVAL) ❑ DOG KENNEL EL DAIRY <br /> Z HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ®-PKG TREATMENT PLANT <br /> O TIERED PERMrn ED FACILITY ❑ MOTELIHOTEL ❑ PUMPERTRUCKNARDICHEMT01 <br /> I TATTOOMODY PIERCING ❑ PQOLISPA R LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Select the types) or flies from the list aboye by ch <br /> the appropriate box(es). At least one rile type MUST be selected. Fax to 209 464-0138 or mail to <br /> address indicated above. <br /> 2. EHD will notify the applicant if any EHD riles exist An appointment for review will be confirmed <br /> approximately rive business days but no later than ten (10) days after receipt of application. The file! <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 n <br /> application may be submitted when the file is available. <br /> 4. Any file not returned in the same condition as released will he reorganized by EHD staff at the expen <br /> or the applicant Future file reviews by the same applicant may require a $93.00 deposit prior to revi <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> . x..; :'r:• - ,TIME ..;,s...:,: .. ... - <br /> LsONF.(RMEDiAPROINThtENj`pATE' a',.. i:?x <br /> ;'DATE.CONFIRSVIED ' " PHONE : .. <br /> FAX i;iNrr1AL$ ' <br /> REVIEWED YES NO REVIEW DATE' <br />