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,DATERECEIVED <br /> EHD LOG NUMBER <br /> ��1`; SAN JOA COUNTY ,,/ <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> O C r 2 420 304 E Weber Ave 3'd Floor Stockton �1 <br /> 09)468-3420 CA 95205 <br /> Fax: (209)464-0138 Web:www.co.san joaquin:ca.usrdh& . <br /> L-'i` -0f4h1E 4T NEALTh: <br /> PERMIT-S,- :r PS PUBLIC RECORDS RELEASE APPLICA ' <br /> APPLICANT: /1 /� �s BUSINESS/AGENCY: <br /> ADDRESS'2c1v C- V 14 H �+I D <br /> PHONEFACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE:Ltz 2y, Time: lav` <br /> (Please allow 10 business days from date of application submittal) <br /> U CHECK BOX TO EXPEDITE REQST- <br /> 3 FE —REQUEST OCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE a <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> G ty <br /> , <br /> 2. sn«, 1„J. ❑ Unit 1 <br /> a. sl ! tc l C G IA ❑ Unit 2 r ti <br /> a. skeel 0 <br /> M <br /> s. steel (IJ i L caE4 3 tVJ' ;� <br /> s. street ► �/ N I <br /> z. Street <br /> city <br /> a. street city <br /> Unit 4 <br /> 9. Street <br /> aty <br /> Unit 10. Street a Un5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> RIINDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> Q'UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> GYfIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARO/CHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> "EDICAL 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)464-0139 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 /> 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 /> 00"42-M <br /> uanao <br />