Laserfiche WebLink
v <br />SEP 0 4 2003 <br />N'MuNMILNT HEALTH <br />pE 1, !�A!T�SERVI 0E5 <br />209-579-2225 <br />MODESTO ATC <br />SAN JOAQUIN COUNTY . 0 <br />EM,'RONMENTAL HEALTH DEPARTMENT <br />304 EAST WESER AVENUE, THIRD FLOOR <br />STOCKTON CA 95202 <br />(209) 468-3420 <br />PUBLIC RECORDS RELEASE APPLICATION <br />EHO LOG NUMBER <br />C� <br />i <br />APPLICANT BUSINESSJAGENCY AAL 75-1- <br />ADDRESS <br />PHONE 5-n — ZZzI FACSIMILE <br />TENTATIVE' APPOINTMENT .DATE 1495i -I[I �'Q3 TIME �4 <br />(plans* give r to 10 business days from date of application submittal) • <br />CHECK BOX TO EXPEDITE REQUEST • $88.00 F E —REQUEST PROCESSED IN 3 BUSINESS GAYS V _• _' I <br />(n <br />SIGNATURE OF APPLICANT tJ%� c__P� <br />NVIRONMENTAL HEALTH DIVISION FILE <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />_ _ _ail•.& loss <br />f <br />OEM <br />FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />❑ UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />DOG KENNEL <br />❑ DAIRY <br />❑ HAZARDOUS WASTE GENERATOR <br />❑ <br />CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />NVIRONMENTAL HEALTH DIVISION FILE <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />HOUSING ABATEMENT <br />❑ SOLID WASTE FACILITY <br />❑ OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ SOLID WASTE VEHICLE <br />❑ UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />DOG KENNEL <br />❑ DAIRY <br />❑ HAZARDOUS WASTE GENERATOR <br />❑ <br />CHICKEN RANCH <br />❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILr Y <br />❑ <br />MOTEL/HOTEL <br />❑ PUMPER TRUCK/YARDICHEM TOILETS <br />❑ TATTOO/BODY PEIRCINO <br />❑ <br />POOL13PA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACILITY <br />❑ <br />OTHER (PLEASE SPECIFY) <br />W <br />1. List up to ten addresses In the space above. Select the type($) 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 mall 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 $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 />�.r'Ol�fl�Nt��":APPOINTNf�1!I:i' d'ATE <br />DATE GONFIRM159 <br />NO <br />PHONE 6bPa4 • INITIALS <br />n�•..e.�..i. R..11thtc ... <br />(,-E7 � f- / M ^�-sl-� L'. FcJ cU /I Cis ^✓YI G Cl Gii7`c� <br />