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SAN JOAQUIN COUNTY <br />.� ENvi. .NMENTAL HEALTH DEPARTML . f <br />304 E Weber Ave 3`d Floor Stockton, CA 95205 <br />(209) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquln.ca.us/ehd <br />PUrBLICC RECORDS RELEASE APPLICATION <br />APPLICANT: SGV �I r��� ; • 1 BUSINESS/AGENCY: <br />ADDRESS: �// c1 �l G�iP C% e Cf' L r ���� �iv'��✓19pi <br />PHONE: Z / / FACSIMILE: <br />TENTATIVE` APPOINTMENT DATE: Time: <br />(Please allow 10 business days from date of application submitta <br />13 CHECK BOX TO EXPEDITE REQUEST - Z9 . � EE — REQUEST PR ESSED IN 3 BUSINESS DAYS <br />SIGNATURE OF APPLICANT ` ,( DATE <br />FILE ADDRESS _ <br />,. Sued S j C o u �. n Z e ��: t — Wiz, ,J <br />2. stree City <br />a. Stree CAY <br />4. Street CRY <br />5. Street oty <br />6. street oty <br />7. Street C <br />6. Street C"Alj�tujlhllrlU� <br />11 <br />9. street City <br />,o. Suet CRY APP— n <br />12- (/ <br />Department Use Only <br />UNIT <br />❑ Unit 1 <br />❑ Unit 2 (�• 1'`� <br />Unit 3 <br />Unit 4 I <br />mew <br />❑ Unit 5 <br />ENVIRONMENTAL HEALTH DEPARTMENT FILES <br />UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br />OTHER CLEANUP SITE (NON -LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br />UNDERGROUND TANK (MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br />HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br />❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDlCHEM TOILE <br />❑ TATTOO/BODY PIERCING ❑ POOLfSPA ❑ LAND USE APPLICATION SITES <br />❑ MEDICAL WASTE FACiLfrY ❑ 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 ff 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 FAXINITIALS <br />REVIEWED YES NO REVIEW DATE <br />EHD 48-02-006 - <br />6/62003 <br />