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SAN J OAQUIN COUNTY <br />ENIGv > 4ENTAL HEALTH DEPART*a <br />!a 3Webec Ave 3rd Floor Stockton, CA 95205 <br />AP <br />R 1 5 ZP9) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/chd <br />/r771r0--pla <br />ADDRESS: <br />i;; 1;�NLTN PUBLIC RECORDS RELEASE APPLICATION <br />(�e4 <br />PHONE: JSjb-676-IvGG <br />MW <br />TENTATIVE' APPOINTMENT DATE: <br />iESS/AGENCY: <br />L�, �-�f� S�S�D 'nenortty �r�niz (n4 �2 <br />FACSIMILE: .5.30"6 7-K, 600 <br />Time: <br />(Please allow 10 business days from date of application submittal) <br />CHECK BOX TO EXPEDITE REQUEST .$93.00 FEES — EST PROCESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT 7j �/. DAT <br />Department Use Only <br />❑ <br />UNIT <br />❑ <br />FILE ADDRESS , <br />❑ <br />❑ Unit 2 <br />Unit 3 <br />36123 <br />tgsf <br />❑ <br />w sT <br />•. <br />❑ <br />2. <br />Sued <br />Ga <br />t <br />>`, u5I <br />1. <br />sued I U <br />L <br />Jt' 457 :4. W <br />4. <br />sedpq irk i- <br />M E <br />S%rfc-F US% <br />SPC <br />5. <br />tre <br />Stl VZJ <br />L' <br />✓ <br />S LIST G <br />6. <br />Street ~ 1 <br />i 4_� <br />"•. •j <br />/ <br />r. <br />str,.( 310 <br />41I`Y184- <br />22t. Misr v <br />r` <br />6. <br />st«2- <br />W <br />. LS i /-i �, <br />a. <br />street <br />y <br />l <br />)�- <br />10. <br />Stred <br />city <br />Department Use Only <br />❑ <br />UNIT <br />❑ <br />❑ Unit 1 <br />❑ <br />❑ Unit 2 <br />Unit 3 <br />1 <br />3 <br />D nit 4 <br />❑ <br />❑ Unit 5 <br />❑ <br />R 1 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES .�! , <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) <br />❑ <br />OTHER CLEANUP SITE (NON -LOP) <br />❑ <br />' UNDERGROUND TANK(MONITORINGIREMOVAL) <br />❑ <br />HAZARDOUS WASTE GENERATOR <br />❑ <br />TIERED PERMITTED FACILITY <br />❑ <br />❑ TAT'TOOIBODY PIERCING <br />❑ <br />❑ MEDICAL WASTE FACILITY <br />❑ <br />HOUSING ABATEMENT ❑ SOUD WASTE FACILITY-- <br />FOOD <br />ACILITY FOOD FACILITY ❑ SOUD WASTE VEHICLE <br />DOG KENNEL ❑ DAIRY - <br />CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />MOTEUHOTEL ❑ PUMPER TRUCKAYARDICHEM TOILETS <br />POOLtSPA ❑ LAND USE APPLICATION SITES <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) 484-0138 or rhaii 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. �-- Of <br />6. Applications received after 3:00 pm will be processed the next business day. :. <br />CONFIRMED-APPOINTMENTUATE TIME ; <br />DATE.CONFIRMED `PHONE FAX '1NRIALS <br />REVIEWED YES NO REVIEW DATE <br />EHD 4842446 <br />8=001 <br />