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Jun. 2, 2005 2.57PM l "LACED GEO No, 0833 P. 1 <br /> DATE RECEIVED SAN JOAQU]N COUNTY EHD LOG NUMBER <br /> ENVIItoNMENTAL HEALTH D AT2T1lIZNT <br /> 3041;Weber Ave 3'd Floor Stockton, CA 95205 ., <br /> JUN, O 2@ )4683420 Fax: (209)464-0138 Web:www.co.san-loaqum.ca.us/ehd <br /> Er�RpNh[NT HEWH p LTC RECORDS RELEASE APPLICATION <br /> APPLICANT: ZLI qq cY�USINESS/AGENCY: nadya,,C e a 6 C4&w4a meA_� <br /> ADDRESS: <br /> PHONE;_ Q7 7' ' � �lJFACSIMILE: Q /,.�rA / % a JUN <br /> TENTATIVE*APPOINTMENT DATE: � Q.� ~Ll�� Time: ��•V 4/ U�'V A{P{ease la husin froAOD8193 <br /> f tion submittal) � <br /> CHEGK BOX TO E7CPEDlTE REQ ST• 93.00 FERE U T PRO USfNESS DAYS <br /> /71 <br /> SIGNATURE OF APPLICANT DATE t$ / hL <br /> Department Use Only / UJ <br /> J/ 1_j FILE ADDRESS UNIT ((( <br /> svaet CittC <br /> street K a L• 9 7yr <br /> � E] Unit 1 <br /> 3 Street CII <br /> (J� ❑ Unit 2 <br /> 4. S., <br /> I'J 6. GbbMat cn �/OL C Unit 3 <br /> 8. Street <br /> �USt T sty OU/$ Unit4 <br /> �T s�e< u e nn <br /> ►+�' r Use a sua� d u) /11/� Unit 5 <br /> dm io. street ut CUWUIJUU <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES �uN <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) d HOUSING ABATEMENT d SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY O SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) A DOG KENNEL 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR d CHICKEN RANCH b PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOLISPA Q LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY d 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(2091464-0138 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 confirtned <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 /> EHh 48-02-M <br /> 8f8l2aW <br />