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-- _moi t�u 0 <br />40 v� <br />l SAN J•OAQUIN COUNTY <br />EN VIR01( MENTAL HEALTFI DEPARTMENT <br />304 U Weber Ave 3`d Floor Stockton, CA 95205 <br />t<v A 168-3420 Fax: (209) 464-0138 Web: www.co.san-joaquinca.us/chd <br />APPLICANT: _ <br />AIIDRESS:,l; <br />PUBLIC RECORDS RELEASE <br />C�K BUSINESSIAGENCY: <br />-fOI�V 41 116 (t -{ . <br />PHONE: 209• ��.FACSIMILE: 909'$35-66'7< <br />l - q <br />TENTATNE",,yFOINTMENT DATE: A 4AR T me: 4 %3d AH <br />. ,. ',,(Please allow 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQUEST - $93.00 FEE - REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT ��y., /Ply c -E'= DATE i lb�G`' <br />Department Use Only <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />ONDERGROUND TANK (USI) CLEANUP SITE (LOP) �}tOUSING ABATEMENT <br />FACILITY <br />THER CLEANUP SITE (NON -LOP) <br />UNDERGROUND TANK(MOtdRORINGIREMOVAL) <br />,, FOOD <br />,fir <br />ROG KENNEL <br />/rte OUS WASTE GENERATOR <br />TIERED PERMITTED FACILITYTEUHOTEL <br />CHICKEN RANCH <br />0 TATTOOIDODYPIERCING <br />MEDICAL WASTE FACILITY <br />12r POOUSPA <br />CI OTHER (PLEASE SPEC <br />i <br />, <br />I <br />� <br />1 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />ONDERGROUND TANK (USI) CLEANUP SITE (LOP) �}tOUSING ABATEMENT <br />FACILITY <br />THER CLEANUP SITE (NON -LOP) <br />UNDERGROUND TANK(MOtdRORINGIREMOVAL) <br />,, FOOD <br />,fir <br />ROG KENNEL <br />/rte OUS WASTE GENERATOR <br />TIERED PERMITTED FACILITYTEUHOTEL <br />CHICKEN RANCH <br />0 TATTOOIDODYPIERCING <br />MEDICAL WASTE FACILITY <br />12r POOUSPA <br />CI OTHER (PLEASE SPEC <br />/ Unit 1 <br />/ Unit 2 <br />/Unit 3 <br />/ Unit 4 <br />/ Unit <br />OLIDWASTE..._...... - <br />SOLID WASTE VEHICLE <br />DAIRY <br />KG TREATMENT PLANT <br />. MPER TRUGKryARD1CHEM TOILETS <br />LAND USE APPLICATION SITES <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 IT any EHD files exist. An appointment for review will be confirmed <br />but I t r than ten (10) days after receipt of application. The files <br />approximately five business daysno a e <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 <br />DATE CONFIRMED <br />REVIEWED YES <br />venoms <br />TIME <br />PHONE. FAX' ' <br />NO . REVIEW DATE <br />INITIALS' <br />