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MAY 1 6 91003 <br />I <br />PPLICANT <br />3DRESS - IIC\. Glr� <br />10NE <br />-SAN JOAQUIN COUNTY <br />ENVIRO`oENTAL HEALTH DEPARTMENTI%d <br />304 EAST WEBER AVENUE, THIRD FLOOR <br />STOCKTON CA 95202 <br />(209) 468-3420 <br />ILIC RECORDS RELEASE APPLICATION <br />),? r-ieX f;=iA <br />0-2- :�.; I I <br />1 FACSIMILE 1631 r 3_7 `1 —'7 E �7 <br />TENTATIVE' APPOINTMENT DATE TIME <br />(Please give 7 to 10 business days from date of application <br />7 CHECK BOX TO EXPEDITE REQUEST -;89.00 FEE —REQUEST PROCESSED IN 3 BUSINESS DAYS <br />LIIU LUG NUMUU: <br />I Fq <br />Cr_ ') <br />01-D <br />IGNATURE OF APPLICANT \, V //(w/ DATE <br />ADDRESSFILE <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />_r <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) <br />❑ <br />DOG KENNEL <br />ENVIRONMENTAL HEALTH DIVISION FILES <br />_r <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) <br />❑ <br />DOG KENNEL <br />❑ DAIRY <br />'HAZARDOUS WASTE GENERATOR <br />❑ <br />CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />_TIERED PERMITTED FACILITY <br />❑ <br />MOTEL/HOTEL <br />O PUMPER TRUCK/YARD/CHEM TOILETS <br />TATTOOIBODY PEIRCING <br />.q❑ <br />POOLISPA <br />❑ LAND US�.APPLICATION SITES <br />MEDICAL WASTE FACILITY <br />/ <br />OTHER (PLEASE SPECIFY) <br />Vvt d' S(Ir'11L f('i �„ LI✓�. <br />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 />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 />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 />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 $89.00 deposit prior to review. <br />'TENTATIVE appointment dates must be confirmed with EHD staff. <br />Applications received after 3:00 pm will be processed the next business day. <br />)NFIRMED APPOINTMENT DATE <br />JE CONFIRMED <br />:VIEWED YES NO <br />am <br />TIME <br />PHONE FAX <br />REVIEW DATE <br />INITIALS <br />