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DATE RECEIVED i SAN JOAQUIN COUNTY • <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 E Weber Ave 3rd Floor Stockton, CA 95205 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.co.sanjoaquin.ca.us/ehd <br />APPLICANT: <br />ADDRESS:_ <br />PHONE: <br />PUBLIC RECORDS RELEASE APPLICATION <br />, 6g-3/05 <br />BUSINESSIAGENCY: <br />, (4 <br />TENTATIVE` APPOINTMENT DATE: <br />ry of S N Vet,falx.^) <br />Time: <br />(Please allow 10 business days from date of application submittal) <br />El CHECK BOX TO EXPEDITE REQST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT �t DATE <br />j R l�k <br />Nak <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />EHD LOG NUMBER <br />Department Use Only O <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 <br />Unit <br />Unit 4 <br />❑ Unit 5 <br />)dUNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />13 <br />HOUSING ABATEMENT <br />HOUSING <br />FILE ADDRESS <br />THER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ DAIRY <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />13 <br />DOG KENNEL <br />CHICKEN RANCH <br />11PKG TREATMENT PLANT <br />HAZARDOUS WASTE GENERATOR <br />❑ <br />l9/ M.(I/`IWS <br />.tet %DiX1 /�lr• <br />G <br />/Y.+t 46 <br />2. <br />6trret <br />8 Q n2c� o.J <br />/9,lf�tvP <br />OTHER (PLEASE SPECIFY) <br />3. <br />sveet <br />A, (`A <br />4. <br />$4 e1 <br />5. <br />Street <br />U <br />6. <br />Street <br />G <br />7. <br />SVeet <br />0 <br />8. <br />Street <br />_ t <br />rl <br />C <br />9. <br />Street <br />,0. <br />Street <br />oty <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />EHD LOG NUMBER <br />Department Use Only O <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 <br />Unit <br />Unit 4 <br />❑ Unit 5 <br />)dUNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />13 <br />HOUSING ABATEMENT <br />HOUSING <br />SOLID WASTE FACILITY <br />❑SOLID WASTE VEHICLE <br />THER CLEANUP SITE (NON -LOP) <br />❑ <br />FOOD FACILITY <br />❑ DAIRY <br />UNDERGROUND TANK (MONITORING/REMOVAL) <br />❑ <br />13 <br />DOG KENNEL <br />CHICKEN RANCH <br />11PKG TREATMENT PLANT <br />HAZARDOUS WASTE GENERATOR <br />❑ <br />MOTELIHOTEL <br />❑ PUMPER TRUCKIYARD/CHEM TOILETS <br />❑ TIERED PERMITTED FACILITY <br />13 <br />❑ <br />POOLISPA <br />❑ LAND USE APPLICATION SITES <br />❑ MEDICALTATTOOIWAS PIERCING <br />❑ MEDICAL WASTE FACILITY <br />❑ <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 be processed the next business day. — <br />CONFIRMED APPOINTMENT DATE TIME <br />DATE CONFIRMED PHONE FAX" INITIALS <br />REVIEWED _ YES NO REVIEW DATE <br />9-1-a(�1 <br />1`b)0 <br />IEO <br />