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• • <br /> EHD LOG NUMBER <br /> DATE RECEIVED SAN J OAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ZOq3 <br /> OC- 4 7 -9004 304 E Weber Ave 3's Floor Stockton,CA 95205 <br /> (209)468-3420 Fax: (209)464-0138 Web: www.co,san-joaqu1n_ca_vs/ohd <br /> PUBLIC RECORDS RELEASE APPLICA'T'ION <br /> �(� CSA wTdt In", <br /> APPLICANT: Jb,G_. Sgl1 ,�. BUSINESS/AGENCY: <br /> ADDRESS: p�( GT.n Sf—reset' SC0..��In. I-f'i <br /> PHONE: (J!)V—q g`-'k8 FACSIMILE: II c$'3 u <br /> TENTATIVE'APPOINTMENT DATE: <br /> lI, 15-10t4 Time: -e 00 PV, <br /> (plane allow 10 buslaeas days from date of applioatlon submittal) <br /> El CHECK BOX TO EXPEDITE REQUEST,$93.00 F -REQUEST PROCES$EU IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT \j DATE <br /> Department Use Only <br /> UNIT <br /> FILE ADDRESS <br /> aw« v§lnd ❑ Unit 1 <br /> a. SUeN <br /> Ckyn r. Y: Unit 2 !i t <br /> C' <br /> sem« c Unita <br /> E Bwel � <br /> c. Unit 4 <br /> ca <br /> ❑ Unit <br /> 9. So-oot <br /> ,D. S4aeI <br /> 4)A;+(0 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ArIUNDERGROUND TANK(UST)CLEANUP SITE(LOP) O HOUSING ABATEMENT SOLID WASTE FACILITY <br /> BOTHER CLEANUP SITE(NON-LOP) 0 FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> frSl UNDERGROUND TANK(MONITORINGIREMOVAL) G DOG KENNEL 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH )5 PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY n MOTELIHOTEL 17 PUMPER TRUCKIYARDICHEM TOILETS <br /> 0 POOLISPA I LAND},I��SE APPLICATION SITES <br /> 13 7A7TOOBODY PIERCING <br /> t7 MEDICAL WASTE FACILITY BOTHER(PLEASE SPECIFY) { C-9i�Z� <br /> 1. List up to ten addresses in the space above. Select the type($)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 IT 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 bo scheduled <br /> d <br /> accordingly. <br /> 3. A file that is actively being worked on by END 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 END 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 /> 51 '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 /> END CBaa006 <br /> MM <br /> Td <br /> Td WdSE:TO 1700E LZ 0 <br /> £886 8£8 60Z : 'ON ENOHd . stsfileud o. aZ punoug WOW <br />