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AUG. 1 1. 1UU� 4.4UNM AUUK EAK I H TECH N0. 6355 P. 1 <br /> DATE RECENED 1 - <br /> �� LJ) '-SAN JOAQM COUNTY EHD LOG NUMBER <br /> IC <br /> ''� rN�O`'MENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3'FIoor Stockton, CA 9205 <br /> AUG 2 7 2(�Qb9)468-3420 Fax; (209) 464-0138 Web: ',vWW-CO-Sar1-jOaquin,ca.us/ehd <br /> j NMH"jT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> CANT: <br /> HUSINESSIAGENCY: o er fd��/tOfo "ES �vtC. <br /> CAN4.r I l�..KA <br /> 4 <br /> ADDRESS: 8 aLo <br /> PHONE: d — 23 —o$/8 FAC5IMILE: <br /> TENTATIVE*APPOINTMENT DATE: fD 'V cr Zop Time: ` d AM <br /> (Phase allow 10 business days from data of aPPllcatlon submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-593.00 FEE- RE EST PR ESSED IN S BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE Z-1- 0 <br /> Departure Use Only <br /> FILE ADDRESS I UNiT <br /> / �. 81ree1 dap vt GI SL4OG fG <br /> 2 sues �y O 97 ❑ Unit 1 <br /> sueec (7 It 2 <br /> G nn (-7 <br /> � <br /> G1 �7� /I a�5 L <br /> 6, suer r v 0. G ( Unit 3 <br /> 7. Street C- 7 - <br /> B. stew 1319 O G L 4 Unit 4 <br /> V. U, -9— 13 fe GI JOFA <br /> ,o. sueec ko& Gtv ❑ Unit 5 <br /> f,�1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FIL <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY SOLID WASTE VEHICLE <br /> Z;KUNDERGROUND TANK(MONrrORING/REMOVAL) ❑ DOG KENNEL 9DAJRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH M PKG TREATMENT PLANT <br /> P-TIERED PERMITTED FACILITY ❑ MOTELh{OTFL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOUSPA --- --G-LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY t3 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. END 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 /> 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 /> k ;App`QMTME T A S'; <br /> DAt� 13'NFli lh ;r, <br /> Yks <br /> rum'i°Z <br /> 13 i ck 1lga6w�j R 5 T 15 C(, 0 A.16d"54)_ <br />