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+ r i <br /> 40)" i <br /> DTE-EIVED, .." <br /> ` SAN JOAQUIN COUNTY � END LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> AUG 3 1 2004 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> (209) 458-3420 Fax: (209) 454-0138 Web: www.co.san joaquin.ca.us/ehd <br /> ENViRc0i�"v1C;` T I ILALTI <br /> PERMM15ERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESSIAGENCY: !i <br /> ADDRESS: <br /> t <br /> PHONE:_ ZUl\ �6FACSIMILE: — a <br /> TENTATIVE*APPOINTMENT DATE: ; !ITime: <br /> (Please allow 10 business days from date of application submittal) <br /> i <br /> ❑ i M <br /> CHECK BOX TO EXPEDITE REQUEST- 93.00 FE REQU ST PROCESSED iN 3 BUSINESS DAYS <br /> , i <br /> SIGNATURE OF APPLICANT �� k DATE <br /> Department Use Only <br /> FILE ADDRESS !{ p UNIT <br /> I. street city x.06 <br /> Unit 1 + <br /> 2. Street o El <br /> 3. Street a Unit 2 <br /> 4. Street uty I <br /> 5, Street <br /> 6. Street City <br /> ' I <br /> 7. Scree! ON VUnit <br /> B. Street ( 4 <br />` 9. street C+ i1 ` <br /> 19. Street Ci 11 it <br /> h f. <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> r>1 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) HOUSING ABATEMENT ji .1113 SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) C] FOOD FACILITY # ❑ SOLID WASTE VEHICLE <br /> I% UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> Z. HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH !❑ PKG TREATMENT PLANT <br /> IA TIERED PERMITTED FACILITY ❑ MOTEIIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOUlSPA �♦ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECT IFY} <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 . At least one file type MUST be selected. ;Fax to 209 464-0138 or mail to the <br /> pP Priate box�es) <br /> address indicated above. i� # <br /> 2. EHD will notify the applicant If any EHD flies exist. An appointment for review will be confirmed <br /> approximately five business days but no later than ten (10) ay s after receipt of application. The files j <br /> will be held for a maximum of five'business days for review. Appointments should be scheduled I <br /> accordingly. ! i <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. It <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 applicantimay require a$93.00 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 APR.OINTMl NT.DATE '_ '_ TIME r <br /> ,PHONE I{FAX = IN3TIALS I <br /> DATE CONFIRMED I i <br /> REVIEWED YES NO REVIEW DATE <br /> y o <br /> EHD 48-02-006 I # <br /> 1!1WfI03 ,h — -iif <br />