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OAT6 RECCIVZ0 EHD LUG NUMBER <br /> SAN JOAQv><NCOUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3"'Floor Stockton, CA 95205 <br /> 1005 (209) 468-3420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.uS/ekd O <br /> ENlSi Ul.`,' ,E,�iT HEALH PUBLIC RECORDS RELEASE APPLICATION <br /> �� 11 ION <br /> �1 , <br /> APPLICANT: CSG BUSINESSIAGENNCY: i nn/11e_.i <br /> ADDRESS; C102- NL.VL- IS2-4Q ra' <br /> PHONE: s5(Q:l- 3 "— FACSIMILE: 3 (R <br /> TENTATIVE"APPOINTMENT DATE: ! to Ie 5 Timo: <br /> (Please allow 10 business days from date of application submittal) <br /> © CHECK BOX TO EXPEDITE REQUEST-$93.011 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 1VI2-100) — <br /> DeDarlment use Only <br /> FILE ADDRESS // UNIT <br /> 1. 31ree1 SIJ > •Yl J+ • GI r I <br /> 2. $nel j2,.g . M ctwv�.-S cl �' ❑ Unit 1 15 <br /> 3. SK'I �1 I tc E: . <br /> h <br /> (tin _ am Sty Sl�t le F � unfit 2 ,0ti <br /> s. svoc40W fr_ p � air �cz p.{iLZ 3 fa6u Unii 3 <br /> 9. <br /> 7. mrc0i SIMM GH � Li:�71Y� ! e2 SPU <br /> DO Unit 4 <br /> 0. s0eei a <br /> 9. 311M c" ED Unit 5 <br /> 10. sveet ci <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> T OTHER CLEANUP SITE(NON-LOP) O 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 ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARU/CHEM TOILETS <br /> ❑ TATTOOIaODY PIERCING ❑ POOU5PA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIE <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 /> EHD 4042-006 <br /> oran60a <br />