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0�A J/LVVY lu.LO CAA I DATE RF- VEp MAR 0 8 2b04 ADDRESS PHONE LUV V40UD41 SAN JCAQUIN COUNTYPUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, THIRD FLOOR STOCKTON CA 95202 (209) 468-3420 PUBLIC RECORDS RELEASE APPLICATION 0e{l BUSINESS/AGENCY FACSIMILE TENTATIVE* APPOINTMENT DATE 3C/L//L/Oyu _ TIME /0441 (Please give 7 to 10 businessad ys iron date of application submittal) wjUUT/UU END LOG NUMBER 17( a CHECK BOJTO EXPEDITE REQUESTF7 00 FEE -REQP9ST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OP APPLICANT / ( C_ DATE SO ENVIRONMENTAL HEALTH DIVISION FILES IIIAAA ar UNDERGROUND TANK(UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY �..tt�w■lpF�yy rG OTHER CLEANUP SIE (NON -LOP) . 13 FOOD FACILITY ❑ SOLID WASTE VEHICLE 2r UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL - ❑ DAIRY O HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ClPKG TREATMENT PLANT 13 TIERED PERML,TTED FACILITY ❑ MOTELIHOTEL ❑ PUMPERTRUCKIYARD/ M TOILETS ❑ TATTOO/BODY, FORCING P •PdOUSPX ` • ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM Q OTHER (PLEASE SPECIFY ABOVE) 1. List up to ten addresses in the space above. Select the type(s) of.fi(es from the list above by check(n( the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mall to the address indicated above.• 2. EHD will notify -the applicant if any EHD files exist An appointment for review will be confirmed. approximately five business days but no later than ten (10) days after receipt of. application. The files will be held for a maximum of five business days for review. Appointments should be scheduled acco5dingly. 3• A filelthat is actively being worked on by EHD staff may not be immediately available for review. A ne, application may be submitted when the file is available. 4. Any file not returned In the Same condition as released will be.reorganized by EHD staff at the expens of the applicant Future file reviews by the same applicant may require a $87.00 deposit prior to reviei S. 'TENTATIVE appointment dates must be confirmed with EHD staff. 6. Appl atlons received after 3:00 pm will be processed the next business day. i CONFIRMED APPOINTMENT DATE DATE CONFIRMED II NO TIME PHONE FAX INITIALS REVIEW DATE , 10 /. ) V / I � I / 1111111_1111111111111111111111111111111�111111111111111�11111111111111111, ■rte► ��w f:1 AIEEII.111�1-. -r Mnl--�nrl IMIiI'MIF''JI�I �III-�II I�� ENVIRONMENTAL HEALTH DIVISION FILES IIIAAA ar UNDERGROUND TANK(UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY �..tt�w■lpF�yy rG OTHER CLEANUP SIE (NON -LOP) . 13 FOOD FACILITY ❑ SOLID WASTE VEHICLE 2r UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL - ❑ DAIRY O HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ClPKG TREATMENT PLANT 13 TIERED PERML,TTED FACILITY ❑ MOTELIHOTEL ❑ PUMPERTRUCKIYARD/ M TOILETS ❑ TATTOO/BODY, FORCING P •PdOUSPX ` • ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM Q OTHER (PLEASE SPECIFY ABOVE) 1. List up to ten addresses in the space above. Select the type(s) of.fi(es from the list above by check(n( the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mall to the address indicated above.• 2. EHD will notify -the applicant if any EHD files exist An appointment for review will be confirmed. approximately five business days but no later than ten (10) days after receipt of. application. The files will be held for a maximum of five business days for review. Appointments should be scheduled acco5dingly. 3• A filelthat is actively being worked on by EHD staff may not be immediately available for review. A ne, application may be submitted when the file is available. 4. Any file not returned In the Same condition as released will be.reorganized by EHD staff at the expens of the applicant Future file reviews by the same applicant may require a $87.00 deposit prior to reviei S. 'TENTATIVE appointment dates must be confirmed with EHD staff. 6. Appl atlons received after 3:00 pm will be processed the next business day. i CONFIRMED APPOINTMENT DATE DATE CONFIRMED II NO TIME PHONE FAX INITIALS REVIEW DATE