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DATE RECElVEO EHD LOG NUMBER <br /> 1 SAN JOA.QUIN COUNTY ti. <br /> ENVIRONMEN'T'AL HEALTH DEPARTMENT <br /> 304 E Weber Avc 3,a Floor Stockton, CA <br /> 952 <br /> 0,324 <br /> (209)468-3420 Fax: (209) 464-0138 Web: www.co.sanjoaquin� <br /> YP <br /> PUBLICRE CORDS RELEASE APPLICATION <br /> APPLICANT: f-."O BUSINESS/AGENCY: f 741&-c <br /> - <br /> ADDRESS: Oto-L- <br /> PHONE: 7 1R--+ - 371T1 FACSIMILE: 3( ej —gZ2-d <br /> TENTATIVE'APPOINTMENT DATE: I �V- /-2' ( /0-;1- Time: 0-0 <br /> Ad <br /> (Please allow 10 business days from date of application I <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCI;S t U _ DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Dopartmenl Use Only <br /> FILE ADDRESS UNIT <br /> 6�i 2910 ^S 2 OI~ deqVi <br /> 11 z sima 2-+1Jw E- 0 ci ❑ Unit1 <br /> (/ siKm �21Z � t W 1 6 1 [] Unit 2 <br /> 3 1 o-(1 <br /> (' strrnl $ 'C �-• 6 - Unit 3 <br /> 2Zfa n Nva + H a <br /> e31 r esti s bl i4uyib t acs 61 <br /> v slron 2 3 3 rS c� �.. 1 - of tRb Unit 4 <br /> LA� o-ecl '2`{• rv�6t,.; o.r�.. t - [( Unit 5 <br /> t• 3tolo 3eSe <br /> ENVIRONMENTAl 1 TH DEPARTt NT FIL <br /> W UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> W OTHER CLEANUP SITE(NON•LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> tQ UNDERGROUND TANK(MONITORINGIREMOVAL),/ ❑ DOG KENNEL ❑ DAIRY <br /> Int HAZARDOUS WASTE GENERATOR-' ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY✓- noAt- ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> Q TATTOO/BODY PIERCING ❑ POOUSPA ❑ 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 inithe 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 /> EHD 46.01406 <br /> aegonl <br />