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SAN J QUIN COUNTYPUBLIC HEALTH •RVICES `1 �L��a,�,�1�� <br />I VIRONMENTAL HEALTH DIVISd 00 �` <br />304 EAST WEBER AVENUE, THIRD FLOOR <br />STOCKTON CA 95202 <br />(209) 468-3420 <br />PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT -e& Z -1 77Z---7) 7---7) BUSINESSIAGENCY_ <br />ADDRESS( 1-7 <br />PHONE A� J 12% _ FACSIMILE <br />TENTATIVE' APPOINTMENT DATE TIME <br />(Please give 7 to 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQUEST - $78.00 FEE — REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT f Z DATE <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />M SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ <br />SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MON ITORINGIREMOVAL) <br />C7 <br />DOG KENNEL <br />0 <br />DAIRY <br />dEr—HAZARDOUS WASTE GENERATOR <br />0 <br />CHICKEN RANCH <br />❑ <br />PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ <br />MOTELIHOTEL <br />❑ <br />PUMPER TRUCKIYARDICHEM TOILETS <br />❑ TATTOOIBODY PEIRCING <br />❑ <br />POOLISPA <br />❑ <br />LAND USE APPLICATION SITES <br />CI MEDICAL WASTE FACILITY <br />❑ <br />PUBLIC WATER SYSTEM <br />❑ <br />OTHER (PLEASE SPECIFY ABOVE) <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 $78.00 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 />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />EFS 00 14 01105100 <br />