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SAN QUIN COUIV7"Ytt3eLiC HEAL-1hvl4La <br /> ENVIRONMENTAL HEALTH DIVISI� <br /> 304 EAST WEBER AVENUE,THIRD FLOORS , <br /> NOv STOCKTON CA 95202 <br /> �EA`5H (209) 468-3420 <br /> EPI R(�f�1 E� <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> B1PPL7CAIN7 _ �.C�.�t'V /l,p}(% BUSINESSIAGENCY Qduah/e7P� f7POEi9U/I^Di�/yJp(J <br /> ADDRESS `7 S// �.y C.0 ll SD Q C CA SvZOS~ <br /> (,;"Q PHONE 7 D J—�011 FACSIMILE a <br /> TENTATIVE'APPOINTMh <br /> ENT DATE zz- -(c TIME t '0 qN-� <br /> (Please give 7 to 10 Losiness tlays from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-57ai,07�EE-REST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT __ (��700 - DATE \\ 20(TDO <br /> Y - <br /> FILE ADDRESS <br /> co <br /> IP <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> tTQ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ADATEMENT In SOLID WASTE FACILITY <br /> 1�OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY Q SOLID WASTE VEHICLE <br /> ❑ UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH 0 PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOO/BODY PEIRCING L7 POO"PA Q LAND USE APPLICATION Srrrg <br /> ❑ MEDICAL WASTE FACU•TTY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFYABOVE) <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 (t 0) 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 Fite is available. <br /> 4. Any file not returned in the same condition a5 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 /> EN OJ 1i Ot10YW - <br />