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_(1EC'08-03 14:59 FROLKOLDER ASSO^ +949-583-2770 T-404 P 02/02 F-034 DATE RECEIVNDi ,, II , SAN JOAQUIN COUNTY II 1 ENVIRONMENTAL HEALTH DEPARTMENT I) E r, �(�n { 304 E Weber Ave 3`d Floor Stockton, CA 95205 r'A 4613=3"420 Fax: (209) 464-0138 Web: w-ww.co.san-joaquin.ca.us/ehd CJI IiU,WoL II .f i i. BLIC RECORDS RELEASE APPLICATION EHD LOG NUMBE APPLICANT: n BUSINESS/AGENCY: Gol(JGy /"Jj SOGeL U.4 _t,ylc ADDRESS: n—��i Ste. IS IVJI n.¢. I CA t9 J_(, I f( PHONE:FACSIMILE: o TENTATIVE" APPOINTMENT DATE: Pte a`a CII Ti -1 Time: r r (Please allow 10 business days from data of application submittal) IJ CHECK BOX TO EXPEDITE REQUEST - 03.00 FEE - REQIy ST PROCESSED IN 3 BUSINESS DAYS SIGNATURE OF APPLICANT DATE ,/VV ENVIRONMENTAL HEALTH DEPARTMENT FILES ts Deoartmenl Use Only UNIT FILE - �DESS Unit 1 ❑ Un U" Unit 4 ❑ Unit 5 ,•� - -W■� -0�t7•ruruz- �tl3®��y,fd�Waw •.ve.-ti.�' �. o�):r�iGLPflrarl�ll Lrfrtr� - -- City ., i Cd In�.nmm� �- 0Oly - ENVIRONMENTAL HEALTH DEPARTMENT FILES ts Deoartmenl Use Only UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACIUTY OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT hQ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS ''�❑j TATTOO/BODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail 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 maxidnum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new 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 expense of the applicant Future file reviews by the same applicant may require a $93.00 deposit prior to review. S. *TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE DATE CONFIRMED REVIEWED YES NO TIME PHONE FAX INITIALS REVIEW DATE 11'. 42t�- UNIT ❑ Unit 1 ❑ Un U" Unit 4 ❑ Unit 5 UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACIUTY OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT hQ TIERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS ''�❑j TATTOO/BODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES ❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASE SPECIFY) 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checking the appropriate box(es). At least one file type MUST be selected. Fax to (209) 464-0138 or mail 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 maxidnum of five business days for review. Appointments should be scheduled accordingly. 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new 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 expense of the applicant Future file reviews by the same applicant may require a $93.00 deposit prior to review. S. *TENTATIVE appointment dates must be confirmed with EHD staff. 6. Applications received after 3:00 pm will be processed the next business day. CONFIRMED APPOINTMENT DATE DATE CONFIRMED REVIEWED YES NO TIME PHONE FAX INITIALS REVIEW DATE 11'. 42t�-