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T <br /> rrDD,aEIVED SAN JOAQUIN COUNTY <br /> EN,-IRC ENTAL HEALTH DEPARTME, <br /> 304 E W e er Ave 3`d Floor Stockton, CA 9520 <br /> 11 <br /> NOV 2 j ZQQ9) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH E�TL PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: HAReALTAID 5- 1/HAIII BUSINESS/AGENCY: S12 KT �N <br /> ADDRESS:�r2 Q—Y-v • '' 11 (, HA 9JZ ' = �AY S�rr�c KTonJ GA 9.SZ0 6� <br /> PHONE:I ZO9 \) aG3 – L4 Oo CrD FACSIMILE: <br /> �� TENTATIVE'APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> X CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE--REQUEST.PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �1E✓r/6�5,/n�tDATE I I �I a3 <br /> �– eparlmenl Use Only <br /> FILE ADDRESS UNIT <br /> 2 cl <br /> iiil U M ❑ Unit 1 . <br /> i. Strcel �J ti LZ cit 1� <br /> 2. St el <br /> a. street – L/ C/ R ar cn �– ❑ Unit 2 t��-✓ <br /> cl <br /> d, Street _ <br /> Ca Unit <br /> 5, Street <br /> Pt <br /> 6. Street <br /> ca Unit 4 <br /> I. SOce, <br /> Cn <br /> 8. Simel <br /> Gil <br /> 9. street <br /> 10. Street CO <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES L <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON•LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> r UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> C TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK)YARDICHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOLISPA ❑ 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 /> 1. Any file not returned in the same condition as released will he reorg y qq.Y a he expense <br /> P <br /> of the applicant. Future file reviews by the same applicant may req 3.0 5 or to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. 11 <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 /> EHD46-02-006 <br /> WW2000 <br /> l <br />