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Sep 02 05 09234a Pi s 40809-1224 p.1 <br />6 t V SAN JOAQUIN COUNTW EHD LOG NUMBER - <br />SEP - 2 2005 ENwRoNMENTALHEALTHDEPARTMENT <br />p 304 E Weber Ave 3d Floor Stockton, CA 95205 Q <br />ENVIRONMENT H�I TV68-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br />PERMIT/SERVICES <br />PUBLIC RECORDS RELEASE APPLICATION <br />ADDRESS: i"S_1D S. Aas cO M Av-e # P. Sc YL To sstc_ ir C9s-2Z <br />PHONE: (TL/'IS I G-(�-:G� FACSIMILE: � 5-i,.Q 4 'n^ <br />TENTATIVE* APPOINTMENT DATE: Time: it f ' I <br />(Please allow 10 business days from date of application submittal) Cop <br />DD + <br />0 CHECK BOX TO EXPEDITE REQUEST - $93 00 €EEE/1-IREE�000EES� T, ,PROCESSED IN 3 BUSINESS DAYS �Lllrtt�r/tJlj((f)JJjI/J' Q Cl Iva / <br />SIGN ATURE OF APPLICANT v ""yrv!/ APA . DATE _ `- 1FILE APORESS <br />Q <br />415 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 <br />,weUnit 3 <br />Unit 4 <br />❑ Unit 5 <br />.E7'UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />0 HOUSING ABATEMENT <br />0 SOLID WASTE FACILITY <br />.OTHER CLEANUP SITE (NON -LOP] <br />0 FOOD FACILITY <br />0 SOLID WASTE VEHICLE <br />TANK(MONITORINGIREMOVAL) <br />0 DOG KENNEL <br />0 DAIRY <br />-,M-UNDERGROUND <br />,Xi -'HAZARDOUS WASTE GENERATOR <br />0 CHICKEN RANCH <br />0 PKG TREATMENT PLANT <br />0 TIERED PERMITTED FACILITY <br />0 MOTELIHOTEL <br />0 PUMPER TRUCKIYARDICHEM TOILETS <br />0 TATTOOIBODY PIERCING <br />0 POOL/SPA <br />0 LAND USE APPLICATION SITES <br />0 MEDICAL WASTE FACILITY <br />- � mr <br />M I WAry0 ZITAa <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 <br />,weUnit 3 <br />Unit 4 <br />❑ Unit 5 <br />.E7'UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />0 HOUSING ABATEMENT <br />0 SOLID WASTE FACILITY <br />.OTHER CLEANUP SITE (NON -LOP] <br />0 FOOD FACILITY <br />0 SOLID WASTE VEHICLE <br />TANK(MONITORINGIREMOVAL) <br />0 DOG KENNEL <br />0 DAIRY <br />-,M-UNDERGROUND <br />,Xi -'HAZARDOUS WASTE GENERATOR <br />0 CHICKEN RANCH <br />0 PKG TREATMENT PLANT <br />0 TIERED PERMITTED FACILITY <br />0 MOTELIHOTEL <br />0 PUMPER TRUCKIYARDICHEM TOILETS <br />0 TATTOOIBODY PIERCING <br />0 POOL/SPA <br />0 LAND USE APPLICATION SITES <br />0 MEDICAL WASTE FACILITY <br />C 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 />S. *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 I <br />EHO 454MG <br />8=003 <br />.0 <br />