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38/03/2004 14:01 209467"'8 AGE STOCKTON PAGE 02/02 <br /> DATE RECEIVED EHD LOG NUMBER <br /> SAN JoAQuIN COUNTY <br /> [RE 1 EI]VE D +NVIRONMENTAL HEALTHDEPARTMENT <br /> 304 E Weber Ave 3`d Floor Stockton, CA 95205 lq#3i <br /> AUG gl)R43420 Fax: (209)464-0138 Web: www.co.sanjoaquin.ca.uS/ehd <br /> ENVIRON LTC RECORDS RELEASE APPLICATION <br /> APPLICANT: ' S BUSINESSIAGENCY:--8 C7 � <br /> ADDRESS: 7 r i )j <br /> PHONE: �` –/ �v '� FACSIMILE:: L &-7 <br /> j> � <br /> TENTATIVE"APPOINTMENT DATE;_ – 1 � –V–t 11mo:_ 'V tn-N <br /> (Plnasa allow 70 business days from date of appliodtlon submluaq <br /> CHECK BOX TO EXPEDITE REQUE 93.00 FEE–REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT — DATE j " 3r Q <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 2. SSI 117LTV [] Unit 1 <br /> s. So- ' o <br /> 4. 8v ❑ Unit ,II <br /> 6. bveet - Li 1 <br /> 3- svan <br /> CRY TUnit3 <br /> Oi4 <br /> B. 3Veei OB <br /> City <br /> e. ate: ❑ u ii <br /> is sn.l U �(1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES U <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY q7-1 Z <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILFTY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINnfREMOVAL) ❑ DOG KENNEL O DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKC TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOofsoDY PIERCING ❑ POOL/SPA ❑ 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 APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br />