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RR) ECE V LE V ENvr rmFaiTAL EIALTB DFPARTMEP` <br />C 1. pho East fiber Avarua, 3`1 Floor, Stockton, b! WW4 -; 08 <br />� 005 Te(ephoua: (209) 468-3420 Fez: (209) 464-0138 Vi'eb: www.sjgov.or8/Chd <br />% 3 <br />ENVIRONMENT HEALTH <br />pU$LiC RECORDS gELEASE APPLICATION <br />APPLICANT: o u rvt . <<+- Y/ `A <br />ADDRESS: t1n, S%r�G�- �-e_ 201 �+/ - ti�a /D/D <br />PHONE m <br />?Z6- fi 3 3 pNONc (2): AGSIMII {�� <br />TENTATIVE' APPOINTIAENT DATE:TIMW <br />ry <br />(Please allow I busin"r d: from data of apPllcation cuboebl--TMl■flvl only -must da wrtflm7edi <br />rs <br />❑ CHECK BOX TO 0CM nS <br />SIGNATURE OF APPLICANT , <br />UNIT DISTRIBUTION - ❑ Unit7 -❑ Unit2 <br />FEE (CASH OR CHECK ONLY ^ REQUPS3T PROCESSED IN 3 RUSW—s DA <br />it J __ DATE 01 -1 <br />O Units ❑ Units <br />Other (eleatr0r13 lTWdmape) <br />EHD USE ONLY <br />ifl Date Range of Informr7tion Requested: Kram <br />to <br />,poo c <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES I ; <br />y TANK N+�CLV.NUP SIR'(LOP) <br />ClHOurNo AaATIOW <br />(3 SOLO WAM FAMITTPA� 4al.t <br />OwAm T= <br />p�UNDfROi�IINO <br />gOTHEi CLeAN� SITa (HON;OPi <br />❑FOOD FACW'N <br />❑ Do KEVNE{, <br />❑ DAIRY <br />+G UNDLRORWNP TANK (M�71TppINWREetNAL) <br />MCKQVFZANCN <br />❑ WA%MARA TRaAT1RNT FLWT <br />Q HAZAROCUI WASTC GENERATOR <br />0 YoTjLrH M <br />❑ PuureRTRUc7)yARWC?'"ToiLrM <br />❑ T1aR13 POWTITYO F=LITY <br />C7 POOUSPA <br />C LANO'Jse AAfUCATTON Sm[S <br />O TAT70PISCOY PIYRMHO <br />d DTNM (PUPjtsPrCI <br />❑ mKorAL WASTE FACILnY <br />... -----. .....,,,.� e.in.v x -an lu.s-anpu - nc=Nd HOLEMY3. <br />Wi13. Awu oar l ry rc.•... •....�.�._. _ _ <br />7. List up to ten addressee in the :pace above. Sebct the types) of files from the list above by chsca D <br />appropriab box(es). At least ons fila typo MUST be:dectsd to 46d D man e a <br />indicates abay� Addrtss nngss will not be accepted -tor additional assista+lcs with fila address", contact <br />the EHD. Applications received attar s_OD pm Alli be proceusd the nazi businelo day. <br />U <br />2 The EHD will notify the appl7carlt anY lDiO Inas An appolntmelrtfor nvwill be confirmed <br />approximately tan (� 0) days after ncaipt of app)ication. The tiin wilt ba held for a maximum of five business <br />days for rovlew. Appointment# should be scheduled accordingly. <br />3• A filo that Is actively being worked an lr{ EifO staff may not he immediately aTraiiabls for review. A now <br />application may be submitted when the file is available, <br />.S. Any Elie not returned in tt;e Sams condition as released will bs reorganized by EHD staff at the expense of the <br />applicant. future file reviews by the some applicant may ngUlrs a 193.00 deposit prior to review. r t <br />Etm+aaz= <br />+moos <br />E <br />TO - Vit FiWi fi1b1hG'JN�1'IMI3 BESO497 9Z Zi EM/Bi/LE <br />