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` � I SAN JUIN COUNTYPUBLIC HEALTH SPICES <br /> )-*-- <br /> � LJ ENVIRONMENTAL HEALTH DIVISIO4011, <br /> y <br /> J oZOOO 304 EAST WEBER AVENUE, THIRD FLOORS % ppp STOCKTON CA 95202 <br /> ���.. ENT � lEA (209) 468-3420 <br /> KTkTH UP. <br /> RECORDS RELEASE APPLICATION <br /> \ PPLICANT \X�n�.7. BU5INESSIAGENCY (JCdian/C�„d FPD&L)l <br /> ADDRESS O�J /L� Wn/� .S Q C' -7 PA �y 5-.2,0S�~ <br /> PHONE 9 411d t7 <br /> -IVD FACSIMILE O{ 4 / — <br /> t`) 4 <br /> ti <br /> �.� � "APPOINTMENT DATE TIME 0• <br /> M. <br /> •j ••_:*"• (Please give 7 to 10 buslne6s(; a From date of applicaUvn submittal) <br /> d D 9.00 FEE wouEST PROCESSED IN 3 BUSINESS DAYS-..a (Z) <br /> r f, <br /> SIGNATUREN6F'A�P�I.ICANT DATE 12O�a <br /> C <br /> FILE ADDRESS <br /> 35, (r Cc <br /> i <br /> ENVI ONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) C FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> .UNDERGROUND TANK(MONITORINGIREMOVAL) M DOG KENNEL 11 DAIRY <br /> HAZARODUS WASTE GENERATOR ❑ CHICKEN RANCH 0 PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKPYARDICHEM TOILETS <br /> ❑ TATTOOMODY PEIRCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM O OTHER(PLEASE SPECIFY ABOVE) <br /> I. 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) 464-0136 or mail to the <br /> address indicated above. <br /> 2. EHD will notify the appllcant 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$78.00 deposit prior to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> S. Applications received after 3:OD 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 /> --- <br /> GH 00 a otro N <br />