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EHD 'LOG NUMBER <br /> Mr,I' u \� <br /> VEp, <br /> r� ,� SAN JOAQu1N COUNTY <br /> ,LnENVIRONMENTAL HEALTH DEPARTMENT <br /> AUG 3 1 2004 304 E Weber Ave 3rd Floor Stockton,CA 95205 <br /> (209)468-3420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> ENVIRUNIME'r l' HEALTH <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESSIAGENCY: <br /> ADDRESS. Nui C <br /> PHONE: La FACSIMILE: J ` <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST- 9_3.00 FE REQU ST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATEl D <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> ,, str«t 06 ❑ Unit 1 <br /> 2. Strecl 3 city <br /> 3. street ON Unit 2 <br /> 4. Street <br /> city <br /> S. street Unit 3 <br /> 6. Street <br /> 7. Street ^fin' Unit 4 <br /> a, Street C ` <br /> 9. Street oty are Unit 5 <br /> 10. Street city <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 16 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) X HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> 14 OTHER CLEANUP SITE(NON-LOP) ❑ FOOD'FACILITY ❑ SOLID WASTE VEHICLE <br /> 19 UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> 0l HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH © PKG TREATMENT PLANT <br /> 0 TIERED PERMITTED FACILITY ❑ MOTELIHOTEL �a PUMPER TRUCKIYARDICHEM TOILETS <br /> 13TATTOOIBODY PIERCING ❑ POOLISPA !'� LAND USE APPLICATION SITES <br /> El 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 APOOINTMENT DATE <br /> . .TIME >: <br /> DA.n c6NFIRMED =-,:PHONE FAX" dNIT1Al5 <br /> REVIEWED .- YES NO <br /> REVIE=W DATE <br /> EHO 4E-02-006 <br /> ar9r2on3 <br />