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DATE RECEIVED EHU LUU NUMbtK <br /> �� j����i�l\`// <br /> , ENVIi SANJOAQUINCOUNTY <br /> u U L�LJ P!�NMENTAL HEALTH DEPARTM& <br /> o nnq 304 E Weber Ave 3`d Floor Stockton, CA 95205 I 1/ <br /> FEB (2002468-3420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH <br /> PERMMQIT/S/ER/nV�.IICE/TUB/LIC RECORDS RELEASE APPLICATION <br /> APPLICANT: I7•I ` !� t-h���l BUSINESSIAGENCY: ✓hw ill ✓"f�(f7-r�1 �" <br /> ADDRESS: <br /> PHONE: FACSIMILE:. <br /> TENTATIVE`APPOINTMENT DATE: Time: • ,471� <br /> rFllll4 • <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT/—;" [ C4� lt- 1�� ��� DATE <br /> Departmen Use Only <br /> FILE ADDRESS UNIT <br /> Uni <br /> 2. SU" d O O G city <br /> s. Stree 3�3rlgl V a ,y� Ute' y� <br /> {. $treN C� T�- Ci - �" <br /> • 5. street 4 !O. [p G It 3 �I <br /> S. street - S T_> I"'14c �!66r '— cityR 20Q4 ,,�..,,/// <br /> 7. SVeN �-p�' U G Unit <br /> a. Street �-S �� <br /> Streetuu�4 OV Ci ElUnit 510. Street T �� ci <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT f—SOLIDWASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL DAIRY <br /> US WASTE GENERATOR ❑ CHICKEN RANCH PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ UMPERTRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOBODY PIERCING ❑ POOVSPA ❑ 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 /> 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 /> EHD 4842406 - <br /> &=003 <br />