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UA C KtULIVED <br /> HL-t-IU LUG IVU141liLft <br /> L� V ED SAN JOAQUIN COUNTY <br /> �S �f �*IRONMENTAL HEALTH DEPA 'MENT <br /> NOV z 12 ) 465-342�04 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> 0 Fax: (209)464-0133 Web: IVVW'W.Co'.san-joaquin.ca.us/clid <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:_118('teA"T::e I BUSINESS/AGENCY: _ IN /y C TO Af <br /> ADDRESS: 5� Q 4,l�IY S-F6r K'T, CA 952o 6` <br /> PHONE12,09 q 3 —u g W FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-))REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTLlrl/-lVu� DATE ( I 2 1 U� <br /> epartment Use Only <br /> FILE ADDRESS ' UNIT <br /> Cil Lt <br /> 1. Stmet '� s' 1 .�, M <br /> lJ9 <br /> 2. Street G/ c,l �„ rA 5�2 EI Unit 1 <br /> 3. Slreel IrICit <br /> 4. Street ctl L-35D ❑ Unit \\; ✓ A <br /> S. Slreel <br /> Cit <br /> 6. Street City Unit <br /> 7. street COY <br /> B. Street 4Unit 4 <br /> Cil <br /> 9. Slreel Cil <br /> 10, Streel City <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES "'t <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(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> G TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> O TATTOO/BODY PIERCING ❑ POOL/SPA ❑ 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 /> *• Any file not returned in the same condition as released will be reorg y � expense <br /> of the applicant. Future file reviews by the same applicant may req 3.0 '3aN. -. 'he <br /> or to review. <br /> �• *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 /> ZHD 48.02-006 <br /> tl8/2003 <br /> �J <br />