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SAN ENVIRONMENTAL <br /> QUIN COUNTYPUBLIC HEALTH "1"6 HEALTH DIVISAS <br /> 304 EAST WEBER AVENUE, THIRD FLOOR <br /> f Ir 3 <br /> STOCKTON CA 95202 <br /> (209) 468-3420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT Q_JQ�Q�N) <br /> L_Lg&� —BUS IN ESSIAIGENCY <br /> ADDRESS <br /> 66 CA Z log Is <br /> 'I"'LE <br /> PHONE '7 <br /> IACSIMILE <br /> TENTATIVE*APPOINTMLNTDATE I"V'� TIME _19*00 <br /> (Please give 7 to 10 k)usina86 day;;from dale of application submittal) <br /> CHECK DON TO EXPEDITE REQUEST-5 FE -R EST PROCESSED 1M 3 BUSINESS GAYS �j��'F�J ��0� �' /) <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS <br /> 1-,0�_S <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) C1 HOUSING A13ATEMENT 13 SOLID WASTE FACILITY <br /> '<OTHER CLEANUP SITE(NON-LOP) C] F-000 FACILITY 0 SOLID WASTE VEHICLE <br /> .R UNDERGROUND TANK(MONITORINOIREI40VAL) n DOG KENNEL 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 0 PK0 TREATMENT PLANT <br /> ❑ TIERED PLIRMI'TTE13 FACILITY 0 MOTELIHOTEL 0 PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOIDODY PEIRGING In POO"PA 0 LAND USE APPLICATION SVrLS <br /> MEDICAL WASTE FACILITY 0 PUBLIC WATER SYSTEM M OTHER(PLEASE SPECIFY ABOVE) <br /> 7. List LIP to ton addresses in the space above, Select the type(5) 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 indirafj1r1tq <br /> 0_above. <br /> 2. EHD will notify the applicant it 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 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 submItt6:d when the file is available. <br /> 4. Any filo not returned in the same condition as released-will be reorganized by EHD staff at the expense <br /> of the applicant. FUturo file reviews by the same applicant may require a$78.00 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 /> EM Cc 14 QiJasffio <br />