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DATE RECEIVED D ID LOG NUMBER SAN.TOAQUIIV COUNTY ENVIRONMENTALHE, ALTH DEPARTMENT 304 E Weber Ave 3rd Floor Stockton, CA 95205 (209) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.cams/ehd OVO APPLICANT: ADDRESS: PUBLIC RECORDS RELEASE r' o' BUSINESS/AGENCY: 2 PM 2145 Q PHONE: 220Z3701 FACSIMILE- �';tof- 427 p TENTATIVE* APPOINTMENT DATE: O < t )`/- / U S Time; 13 d a i an - (Please allow 10 business days from date of application submittal) CHECK BOX TO EXPEDITE REQ ST -S93 EQUEST PROCESSED IN 3 BUSINESS DAYS 11 SIGNATURE OF APPLICANT DATE ric�1 d -t U ``INI Ir rIF Ltsr wif IF VAlf fj F Department Use Only UNIT ❑ Unit 1 C1 Unit 2 01 *orUnit 4 ❑ Unit 5 ENVIRONMENTAL HEALTH DEPARTMENT FILES VCT -2.0 2005 WUNDERGROUND TANK (UST) CLEANUP SITE (LOP) W OTHER CLEANUP SITE (NON -LOP) C1/UNDERGROUND TANK (MONItORING/REMOVAL) LS�FiAZARDOUS WASTE GENERATOR Cif TIERED PERMITTED FACILITY O TATTOOl130DY PIERCING ❑ MEDICAL WASTE FACILITY �y Ake O N ❑ HOUSING ABATEMENT ❑ FOOD FACILITY ❑ SOLID WASTE FACILITY ❑ SOLID WASTE VEHICLE ❑ DOG KENNEL ❑ DAIRY FILE ADDRESS ❑ PKG TREATMENT PLANT ❑ MOTELIFIOTEL 1, street ❑ LAND USE APPLICATION SITES y (C. Hy CI 2. Streat of) t/i1V -1 5C - f"1 CI 3. $,MCI DRI r�4a f4'� . 1 Z. Hy CII �, CAA WVAX+$ n. Street 120%q 1 E, i7f IZA: 12- H cn SIM 7--L 5�. fiNk c„"� et9u S. SIMel 4L415b ILJ, a - Qk ,%V -11 cily utm T. SIM01 c2DHaa_ E. $�. (2t IZhY cm _5 Wwtavt_ 9. SIMM Ca a. fo, S]"I Strcal Cil CI Department Use Only UNIT ❑ Unit 1 C1 Unit 2 01 *orUnit 4 ❑ Unit 5 ENVIRONMENTAL HEALTH DEPARTMENT FILES VCT -2.0 2005 WUNDERGROUND TANK (UST) CLEANUP SITE (LOP) W OTHER CLEANUP SITE (NON -LOP) C1/UNDERGROUND TANK (MONItORING/REMOVAL) LS�FiAZARDOUS WASTE GENERATOR Cif TIERED PERMITTED FACILITY O TATTOOl130DY PIERCING ❑ MEDICAL WASTE FACILITY �y Ake O N ❑ HOUSING ABATEMENT ❑ FOOD FACILITY ❑ SOLID WASTE FACILITY ❑ SOLID WASTE VEHICLE ❑ DOG KENNEL ❑ DAIRY ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT ❑ MOTELIFIOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILET ❑ POOLISPA ❑ LAND USE APPLICATION SITES ❑ OTHER (PLEASE SPECIFY)_ 1. List up to ten addresses in the space above. Select the type(s) of files from the list above by checkil� the appropriate box(es). At least one file type MUST be selected. Fax to 209 m 464-0138 or ail 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 file will beheld for a maximum 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 fife is available. 4. Any file not returned in the same condition as released will be reorganized by EHD staff at the expe a of the applicant. Future file reviews by the same applicant may require a $93,00 deposit prior to re 5. "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 TIME DATE CONFIRMED PHONE FAX INITIALS REVIEWED YES NO REVIEW DATE EHD 4042-00r DIM003