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DATE RECEIVED _ <br /> -F-r SAN JOAQUIN COUNTY LHO LOG NUMu-_i: <br /> EN,'N�ONMENTAL HEALTH DEPART*NT <br /> 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br /> SEP 2 4(Nq 468-3420 Fax: (209) .464-0138 Web: www.co.san joaquin.ca.us/ehd <br /> tiFP1 <br /> cNVIRONIVN'F I <br /> HEALTH <br /> uFRRAiPUBLIC RECORDS RELEASE APPLICATION <br /> T rCES <br /> APPLICANT: A,/,V/'I--/T k/a• �'-� BUSINESS/AGENCY: <br /> ADDRESS: )`7 C- `�?' /��0 /{ <br /> PHONE: 6 "/2FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE:_ (O/�/C) <br /> r; �Time ,pe *V-,17 <br /> (Please allow 10 business days from date of application submitt I) <br /> QFP PP <br /> CHECK BOX TO EXPEDITE REQUEST.$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS yu <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> Street ZD City ❑ Unit 1 <br /> ]. Street Cit <br /> ❑ Unit 2 <br /> 4. Street pl <br /> s. Street C'1 - --- Unit 3 <br /> 6. Street C <br /> 7, Street Unit 4 <br /> a. Street c: <br /> 9. Street City <br /> ❑ Unit 5 <br /> 10. Street q Off — 0 11 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> 8.OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING _ ❑ POOUSPA ❑ 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 file 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 /> S. "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 4"2-006 <br /> 6/6200] <br />