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01/07/2002 16:07 2094671116 AE S[Ui,KIU,I r,- 11 Ll, U, <br /> % > uwm n...... EHD LOG NUMBER <br /> SAN JOA"IN COUNTYPUBLIC HEALTH SEF,,,-ES <br /> C ENVIRONMENTAL HEALTH DIVISION <br /> J 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STOCKTON CA 95202 <br /> 22 (209)466-3420 <br /> # J PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANBUSINESSlAGENCY d!— a• <br /> ADDRESS* Q <br /> PHONE V/117-/00/0 F CSIMILE <br /> TENTATIVE'APPOINTMENT DATE / t 1 Q 1/11/Ce- TIME A&M <br /> (Plaase give 7 to l business days from dale of application submittal) <br /> /7kCHECK BOX TO EXPEDITE REQU $78.00 FEE—RE U ST PR CESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS O <br /> f t <br /> it <br /> 3 If ft <br /> 1f if <br /> ENVIRONMENTAL HEALTH DIVISION 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(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR O CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELMOTEL ❑ PUMPER TRUCKNARD/CHEM TOILETS <br /> ❑ TATTOG)BODYPEIRCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY CI PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses In the space above. Select the types) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to (209)454-0138 or mail to the <br /> address indicated a owe. <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 returried 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$78.00 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 /> EH 00 14 ofms <br />