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05/03/2005 13:09 209522119 GEOLOGICAL TECHN <br />�= D SAN JOAQUIN COUNTY <br />u u ENVIRONMENTAL HEALTH DEPARTMENT <br />MAY 0 3 7005 304 E Weber Ave 3'd Floor Stockton, CA 95205 <br />(209) 468-3420 Fax: (209) 464-0138 Web: vvvvw.co.san-joaquin.ca.us/ehd <br />ENVIRONMENT HEALTH <br />PFPfMT/SERV!CES PUBLIC RECORDS RELEASE APPLICATION <br />PAGE 01/0 <br />EHD LOG NUMBER <br />7 *1 <br />$a " <br />AppuCANT:.�e-�t�,�„e.LSc- 6U81NESS/AGENCY: Gi0lo �t cw\ TCc1...;cf 1ne <br />AODRESS:y Q 1 <br />PHONE: �d'j s - 9 11 �I FACSIMILE: a.O 9 _ S �.i.4 J.�1 <br />a I' A <br />TENTATIVE- APPOINTMENT DATE: 0 LS Tkm:` <br />T'o <br />(Please allow 10 business days ltom data or application s4t4�40 <br />CHECK BOX TO EXPEDITE REQUEST - $93.00 PEE - REQUEST PROCESSED IN S BUSINGSIGNATURE OF APPLICANTW R9,A S <br />/� I Dapatt nein UW OnIV <br />US'f <br />�T <br />NIF <br />�LAST <br />"v Nv �usT <br />uS <br />ENVIRONMENTAL HEALTH DEPARTMENT I'll -JO <br />uNtr <br />❑ Unft 1 <br />.mil 2 <br />Unit 3 <br />D Unit 4 <br />[] Unit 5 <br />31 <br />I <br />■ UNbEROROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSINO ABATEMENT <br />❑ SWO WASTE FACILITY <br />FILE ADDRESS <br />❑ FOOD FACILITY <br />0 $BUD WASTE VEHICLE <br />A <br />0 UNDERGROUND TANK paGWTORING(REMOVAL) <br />O DOG KENNEL <br />❑ DAIRY <br />0 HAZARDOUS WASTE GENERATOR <br />In CHICKEN RANCH <br />snow <br />55 <br />GCgr,,$ L',na- <br />'Trac. <br />F <br />soak <br />Si i <br />G eo�ni W �- <br />Tr- 4 <br />4. <br />a, <br />smw <br />a.3 -IS <br />'Tr•w wcl (NTra4 <br />a, <br />Saaw <br />3 L <br />7. <br />soyw <br />e. <br />ssan <br />e. <br />Ia. <br />Sew <br />ENVIRONMENTAL HEALTH DEPARTMENT I'll -JO <br />uNtr <br />❑ Unft 1 <br />.mil 2 <br />Unit 3 <br />D Unit 4 <br />[] Unit 5 <br />31 <br />I <br />■ UNbEROROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSINO ABATEMENT <br />❑ SWO WASTE FACILITY <br />■ OTHER CLEANUP WE (NON -LOP) <br />❑ FOOD FACILITY <br />0 $BUD WASTE VEHICLE <br />A <br />0 UNDERGROUND TANK paGWTORING(REMOVAL) <br />O DOG KENNEL <br />❑ DAIRY <br />0 HAZARDOUS WASTE GENERATOR <br />In CHICKEN RANCH <br />O PKO TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />M MOTEUHOTEL <br />17 PUMPER TRUCKIYARDICHEM TOILETS <br />G TATTOOMODY PIERCING <br />O POOLISPA <br />❑ LAND USE APPLICATION SITES <br />O MEDICAL WASTE FACILITY <br />In OTHER (PLEASE SPECIFY) <br />1 List up to ten addressee in the space above Select the hma(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) 484-0139 Gr mall tG the <br />address Indicated above. <br />2. END will notify the applicant If any EHD files exist An appointment for review will be confirmed <br />approximately flee 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 fila Is available. <br />4. Any file not returned In the same condition as released will be reorganimd 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 />9. 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 />rdnnm <br />