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Sep 07 04 04:15p <br />DATE RECEIVED EHD LOG NUMBER <br />SAN JoAQu>rr COUNTY <br />" Yla'cfE) N*ENTALHEALTH DEPARTMENT <br />`( 364VWe6er Ave 3dFloor Stockton, CA 95205 <br />(6r�tp_3420Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br />P <br />`I // H 4: 19 <br />j/ PUBLIC RECORDS RELEASE APPLICATION <br />APPLICANT: Lie,•S� BUSINESSIAGENCY:4/51�TBG C/Vt,"i 1'✓t�P✓i�(/[, <br />ADDRESS: 1 L' d _�U: 'i P. 26*1-Z1y <br />PHONE: O-)(/ -- D I I— y_b J % FACSIMILE: I7 761 — <br />TENTATIVE' APPOINTMENT DATE: <br />(Please allow 10 business days from date of application submittal) <br />C1 CHECK BOX TO EXPEDITE REQUEST - $93.00 FEE —REQUEST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT��7 i r -i— DATE <br />V <br />IN <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />FILE ADDRESS <br />OTHER CLEANUP SITE (NON -LOP) <br />1. <br />S4 et 3 <br />7 Q <br />o <br />❑ DAIRY <br />L <br />2. <br />sweet 'Z S <br />C B <br />06} <br />❑ PUMPER TRUCKIYARD/CHEM TOILETS <br />c�y 7rpq-LIVU <br />3. <br />Slreel <br />❑ MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <br />Oty <br />1. <br />SO l <br />cay <br />5. <br />S9 t <br />CI <br />6. <br />Sv t <br />Seel <br />C' <br />1 <br />9. <br />SVeM <br />10. <br />Sheel <br />coy <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />UNDERGROUND TANK(MONfTORING/REMOVAL) <br />❑ DOG KENNEL <br />❑ DAIRY <br />HAZARDOUS WASTE GENERATOR - <br />❑ CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY <br />❑ MOTELIHOTEL <br />❑ PUMPER TRUCKIYARD/CHEM TOILETS <br />❑ TATTOO/BODY PIERCING <br />❑ POOVSPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ OTHER (PLEASE SPECIFY) <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) 464-0138 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 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 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 $93.00 deposit prior to review. <br />5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br />6. Applications received after 3:00 pm will he processed the next business day. <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX INITIALS <br />REVIEWED YES NO REVIEW DATE <br />ENn d8M-066 <br />maou <br />