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J'3 � • <br /> \ , c ty uvv lrtVrvl•ICIYI HL ItCIALIf1 NAta �� <br /> V trz-J-O-AQUIN COUNTYPUBLIC HEALTH SERVIG11 oit <br /> ENVIRONMENTAL HEALTH DIVISION <br /> I !i 304 EAST WEBER AVENUE,THIRD FLOOR g g , <br /> STOCKTON CA 95202 <br /> (209)468-3420 <br /> J9LJEILIC RECORDS RELEASE APPLICATION <br /> APPLICANT <br /> n�Q SUSINESSIAGENCY �Z <br /> AO0RESS'l 03 0a <br /> PHONE 5 JV � — FACSIMILE 510— — <br /> TENTATIVE•ApP01NTMENTDATE ASA {� <br /> (Please plve to i�as rrcm dal f aPpll TIME <br /> auemlaa0 <br /> 7-1 S • <br /> CHECK 60X TO EXPEDITE RE E T-S89, Q �REQVEST PROCE �SINESS DAYS <br /> 'SIGNATUREOFAPPLICANT JUN 2 <br /> DATE b /S aZ <br /> \ FILE ADDRESS THIS 510E EHD STAFF USE ONLY <br /> v PROGRAM ELEMENTS SEARCH <br /> 1 <br /> - <br /> a0 <br /> nn <br /> �/ ENVIRONMENTAL HEALTH DIVISION FILES <br /> R�.UNDERGROUND TANK(UST)CLEANUP SITE(LOP) CO HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP Sll'E(NON-LDp) ❑ F00o FACILITY O SOLID WASTE VEHICLE <br /> ❑ NDERGROUNO TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> AZARDOUS WASTE GENERATOR O CHICKEN RANCH CI PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL " ❑ PUMPER TRUCKlYARD1CHEM TOILETS <br /> ❑ TATTOOIBODY PEIRCING O POOLISPA ❑ LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY ❑ PURLIC WATER SYSTEM O 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 least one file type MUST be selected. Fax tD 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 ten(10) days after receipt of application. The files <br /> will be held for a maximum Of five business days for review. Appointments should bo scheduled <br /> accordingly, <br /> 3. A file that is aetively being worked on by EHO 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 /> 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 /> REVIEWED YES NO REVIEW DATE <br /> uslaoe <br /> 20120'd 8£T0179V60ET 01 bd VE:OT 2002 01 Nnf <br />