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DATE RECEIVED trlu�v�nvmucn <br /> W ECC SIV L5 1 SAN JOAQUIN COUNTY <br /> ENVI%TNMENTAL HEALTH DEPARTMA <br /> FEB0�)2�1�4 304 E Weber Ave P Floor Stockton, CA 95205 I �� <br /> (23420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICETUB/LIC RECORDS RELEASE <br /> /APPLICATION <br /> APPLICANT:�I ( BUSINESSIAGENCY: ✓,Cl�l� CJI ✓Y�C�/�Ij1D <br /> ADDRESS: Oj-` <br /> PHONE: FACSIMILE:__ <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) F <br /> CHECK BOX TO EXPEDITE REQUEST.$93.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTS � -` DATE <br /> Departmen Use Only <br /> FILE ADDRESS UNIT <br /> • 1. Street b ] ��4 ✓ G <br /> ❑ t�mit <br /> 2 Street 3a o O G aty <br /> 7. SUeet 3v S0�('+ v Qy UnH \ <br /> a. sweet Oty <br /> • <br /> S. sheet .3 4 0 //OO a It 3 <br /> 6. Street pi q-?' r'14c �!(��r o 04 <br /> '' SUr 2 fir, o Unit 4 <br /> 6. Street -2— J \ CAY <br /> 0 9, StreN 7'�C� V city ❑ Unit <br /> 10. Street .2 q ;Ltr rity <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY SOLID <br /> WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL OT DAIRY <br /> ARDOUS WASTE GENERATOR ❑ CHICKEN RANCH 7IZrPKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ UMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ 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 be processed the next business day. <br /> CONFIRMED APP61NTMENTDATE TIME <br /> DATE CONFIRMED PHONE FAX' . INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 4842-006 <br /> WM003 <br />