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Vlll <br /> EI IU tOG NUMUEN <br /> SAN JO IN COUNTYPUBLIC HEALTH SOVICES �h t <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 1. 04 EAST WEBER AVENUE,THIRD FLOOR <br /> O ,rq"!!7 Ctrl/I( (= STOCKTON CA 9520210 <br /> 0 IZ <br /> (209) 468-3420 / U <br /> ' 02 OCT 16 PR ECIC RECORDS RELEASE APPLICATION ENVIRONMENT HEALTH <br /> APPLICANT )'•/�J-�.e.�J ( /�c BUSINESSIAGENC_Y e&// �1 dtL^Q� 5)(r t+tLj LlP <br /> ADDRESS OCi5 JS G'�n....c� ��vc S do p( \! (• QIP <br /> PHONE( / -I ^SrY33 FACSIMILE <br /> TENTATIVE'APPOINTMENT DATE TIME 9!icy /A <br /> (Please Dive 7 to 10 busln bp days dale o pplicalion submittal) <br /> ir <br /> CHECK BOX TO EXPEDITE REQUEST -R" P SS 0'1N3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS THIS SIDE EHO STAFF USE ONLY A <br /> PROGRAM ELEMENTS SEARCH V <br /> Lr2 S <br /> D <br /> O5 <br /> V l// <br /> �l D <br /> J ENVIRONMENTAL HEALTH DIVISION FILES <br /> DERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT. O SOLID WASTE FACILITY <br /> YYYYYUlllllJ�HER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> b UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOIDODY PEIRCING ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <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 (east 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 ton (10) days after receipt of application. The files <br /> w((I 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 $89.00 deposit prior to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> G. 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 * r <br /> •p nlgOf—� f ____ <br />