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i <br /> 1 Jun. 2. 2005 2.57PM. A-flICED GEONo. 0833 P. 1 <br /> 14 * .; DATE RECEIVED SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> R � <br /> E'D <br /> ENVIRONMENTAL HEALTH D ARTMENT _ <br /> 304 E Weber Ave 3'Floor Stockton, CA 95205 V <br /> 7 H <br /> jVy 0 2 Z )468-3420 Fay: (209)464-0138 Web:www.co,san-joaquin.ca.us/chd <br /> EWFiD WENT H"LTH p LIC RECORDS RELEASE APPLICATION <br /> APPLICANT: zQ PUSINESSIAGENCY//��QD�UQ/'tC <br /> ADDRESS: 02 � S7bc (N <br /> PHONE:_6709-7 - a- W7-611P <br /> _ <br /> FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE; & Qs- ~uJk(+1 Tim&: ��• �� <br /> aST- <br /> PFE <br /> usiqUT <br /> rom of ap I tion aubrn'dtai) <br /> CHECK BOX TO EXPEDITE REROESD1 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATEtl L� / <br /> Department Ube QnIY �I �� <br /> n.} > FILE AbDRESS UNIT <br /> 9^rl i eueet IC L tr �'s� ❑ Unit 1 <br /> a sr��eCRV <br /> IJ IF 1. '9"m UI e d Unit 2 <br /> 1q) s $°"" a.C Unit 3 <br /> �• <br /> 45r , SVet A If F 1001SAS <br /> Unit 4 <br /> u�T th <br /> U <br /> H+►' r�ST e. Sveet d iVI� Unit 5 <br /> d IT after R3 2n Crfi&t I ime Rd cw 7m C <br /> ENVIRONMENTAL.HEALTH DEPARTMENT FILES <br /> UNDIERGROUND TANK(UST)CLEANUP SITE{LOP) 0 HOUSING A13ATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) EI FOOD FACILITY b SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIRVMOVAL) R DOG KENNEL D DAIRY <br /> HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH tJ PKG TREATMENT PLANT <br /> TIERED PEMTTED FACILITY ❑ MOTELIHOTEL E7 PUMPER TRUCKIYAROIGHEM TOILETS <br /> D TATTOOMODY p1ERCING ❑ POOLISPA O LAND USE APPLICATION SITES <br /> CI MEDICAL WASTE FACILITY d 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(2091464-0138 or mail to the <br /> address indicated above. <br /> 21 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 buslneSS 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$83.00 deposit prior to review. <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 /> CONE)RMr=D'AI iP0iNTMENT:DATE 1IME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> .ftE ..LEWED YES NO .REVIEW DATE <br /> Elib 4U-IM" <br /> Ef&lZo0.3 <br />