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DATE RECEIVED -SAN JOAQUIN COUNTY , END LU6 NUl,ibcn <br /> � � <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> F,i. 'r1EA1.11B04 E Weber Ave 3rd Floor Stockton, CA 95205 03117' I"('2'495WMI-1f 420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> 03 AUG 13 AM ITALIC RECORDS RELEASEAPPLICATION <br /> APPLICANT: _�Oq'(V DC <br /> L BUSINESS/AGENCY: <br /> ADDRESS: <br /> PHONE: �L�7 _ �/'��/ FACSIMILE: r <br /> TENTATIVE APPOINTMENT DATE: � �/.� ' <br /> (Please allow 10 business days from date of applica to tY 6miEtal 03 <br /> CHECK BOX TO EXPEDITE REQUEST 93.00 FEE-RE EST PR CESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT REQUEST <br /> g iGG DATE <br /> i <br /> Department Use Only <br /> >FILE ADDRESS UNIT <br /> 1. Street /- C `3 '�F Z0-1 o,y Unit 1 <br /> Street i. O C �+ S- �� �l0 Cit /.<. c <br /> 0. Street `rJ �;2ci ❑ U <br /> a. Sireei ZD 317 city <br /> 5. Street Cu ti. w CityUnit 3 <br /> B. Street Cil <br /> 7. Slreel <br /> ON nit 4 <br /> B. Street MR RiP5111 Ir nn <br /> 9. Street ❑ Unit 5 <br /> 10, Street Day , <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES �I c <br /> F1 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY /^ <br /> ❑ OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> A UNDERGROUND TANK(MONITORINGIREMOVAL) Cl DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELMOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOLISPA - ❑ 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 /> EMD 4M24106 - <br /> WM003 <br />