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A— PAGE 01 <br /> 09/17/2003 11:04 2095:10 <br /> r1 <br /> PaGE_ 01. <br /> 09/17/2003 10:12 4640138 <br /> ENVIRONMENTAL <br /> Nc STN <br /> DATF-R 1 IVEo _-, _ - SAN JOAQUIN COUNTY <br /> � r�';`,�il!�_(�) E1W<RONMEN�AI,)HEALTH DEPART' <br /> �l <br /> 304 E Webcr Ave 3rd Floor Stockton,CA 5 u05 ca.us/chdjqqj <br /> SEP 1 �,ZA04 9-3420 Fnx: (209)464-0138 Web:www.cO.san-j a <br /> --NviRUNN,IENT HEAD <br /> HvSv�'�N C RCORDS RELEASE APPLICATION <br /> 11 � BUSINESS/AGENCY:C ` / <br /> /C' <br /> APPLICANT: <br /> ADDRESS: P FACSIMILE' o <br /> PHONE: TITA: <br /> TENTATIVE*APPOINTMENT DATE:.r---�•-� mmrAll <br /> tPj ase allow 10 business days from date of 2130catlon sub <br /> CHECK BOX TO EXPBDIT6 REQUEST-$93-00 FEE-REQUEST PROCESSED IN]eusllvEss DAYS <br /> g7E _ <br /> Department Use Only <br /> SIGNATURE OF APPLICANT UNIT <br /> FILE ADDRESS Unit 1 <br /> Unit 2 o <br /> O �y�iQ�c12 <br /> ere 1 <br /> ML <br /> 4 Suer. U ` <br /> �Unit <br /> i sr.r C Unit 5 <br /> 0 <br /> Sir + <br /> el ENVIRONMENTAL HEALTH T)EPARTMENTI SOLID WASTE FACILITY <br /> O HOUSING ABATEMENT ❑ SOLID WASTE VEHICLE <br /> K UST)CLEANUP SITE(LOP) D FOOD FACILrrY ❑ DAIRY <br /> (lI� UNDIERGR0UN0 TAN 1 DOG KENNEL CI PKG TREATMENT PLANT <br /> d OTHER CLEANUP SITE(NON•LOP) O CHICKEN RANCH ❑ PUMPER TRUC�ARDICHEM TOILETS <br /> G UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ MICKENOTEL U LAND USE APPLICATION SITES <br /> U HAZARDOUS WASTE GENERATOR O POOL/SPA <br /> CJ Tl "D PERMITTED FACILITY O OTHER(PLEASE SPECIFY) Checking <br /> O TATTOO/BODY PIERCING <br /> ❑ MEDICAL WASTE FACILITY of tiles fro 091644, or by <br /> to the <br /> addresses in the specs above• MUSTlect the <br /> be selected. Fax to 2 <br /> List UP to ten a es At least one file tyP <br /> 1' box( )• <br /> ed <br /> the appropriatepve, lntment for review will <br /> bllcat ofnmThe tiles <br /> d r• s Indicated llcant If any EHD tiles exist. An appointment days aftK receipt o PP <br /> 2 EHp W111 notify the app 'daysness but no later than ten( ) ointments should bQ scheduled <br /> approximately five aXimum off fve business days for review. APP <br /> will be held for a m not be immediately available for review. A new <br /> occordinglY 1 worked on by FHD staff may enae <br /> A file that is actively being EHD staff at the exp <br /> �• be submitted when the file ozaQlelased will be reorgani2ed 3. sit prior to review. <br /> application may, llcant may require a$93.00 dopa <br /> 4 Any the not returned in the sable co b 1 the some aPP <br /> of the aPP <br /> Ilcant. Future file reviews Y confirmed with EHD staff. <br /> +TENTATNE aPPaintrTlent dates mustbe <br /> be processed the next business day <br /> 6 Ilcations received atter 3:00 p <br /> 6. APP� .�-•------ TIME <br /> CONFIRMED APPOINTMENT DATE FAX INMALS �— <br /> PHONE <br /> PATE CONFIRMED NO REVIEW DATE <br /> REVIENIED YES <br /> wuzwa <br />