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Ell"400 NUMDen <br /> SAN JOUIN COUNTYPUBLIC HEALTH S ICES <br /> E VIRONMENTAL HEALTH DIVISION <br /> v 04 EAST WEBER AVENUE,THIRD FLOOR <br /> i!ii'?tNi+;L !IEALlf1� '�}/��L 12� <br /> O ,11,11 FD\'WIr STOCKTONCA95202 <br /> (209) 468-3420 <br /> C RECORDS RELEASE APPLICATION ENVIROfdMEfJT HEALTH <br /> 02 OCT 16 PR � " <br /> APPLICANT /ti 5 BUSINESSIAGENCY / U6 C�� �lP <br /> I'( <br /> ADDRESS 2�'S <br /> I/ Gia-vc vYl 5 <br /> PHONE( Z09 -7 1—.:SF'?_3o FACSIMILE /�M <br /> / <br /> 1 TENTATIVE'APPOINTMENT DATE �� I�3 I TIME FACSIMILE -3o 1 <br /> (Please give 7 to 10 burin days date o pplicalion submittal) <br /> CHECK BOX TO EXPEDITE REQU E�O�FE�AEST PCSS IN J BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> G(2 5 <br /> D 9( <br /> 5 <br /> - <br /> ,�I - <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> /J ❑ HOUSING ABATEMENT. ❑ SOLID WASTE FACILITY <br /> A JFF7HER CLEANUP <br /> TANK(UST)CLEANUP SITE(LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> yyyfff�HER CLEANUP SITE(NON-LOP) ❑ DOG KENNEL ❑ DAIRY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> O HAZARDOUS WASTE GENERATOR ❑ MOTEUHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOIDODYPCIRCING ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE-) <br /> ❑ MEDICAL WASTE FACILITY <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) 464-018 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 /> will be held for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> a. 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 )h 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 /> 6. 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 /> M.r <br /> REVIEWED YES NO REVIEW DATE <br /> 0 0140 <br />