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Sep ` 15 04-06: 31a"' pier s 408 55(9-1224 p 1' <br /> BATE RECEIVED EHD LOG NUMBERR9 SANJoAQuW COUNTY <br /> a <br /> ENVIRONMENTAL HEALTIT DEPARTMENT <br /> 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> SEP 5 ZO*09)468-3420 Fax: (209) 464-0138 Wcb:«rww.co.san:joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> P11101:11Q En+�,r� <br /> AppLICQNT: 7 /� �NJ BUSiNESSIAGENCY: 'J� 1 t"l S�rul <br /> ADDRESS: kl�J�/0 S. &-SCAN, f�y 5' PI c�✓L l e) S� CA 95L _ <br /> PHONE: ('f 0 )a"[G-c'�Q-- FACSI4MILE: "�-aD'4 <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$4 .DO FEE-REQUEST P ESSED IN 3 BUS INISS DMS <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> f FILE ADDRESS �+� UNIT <br /> 1. Street 3JC W Ver fk, CI T/-CLCUnit 1 <br /> 2. Street city <br /> 3. Street CRY <br /> © Unit 2 <br /> A. street <br /> 5, steel CRY Unit 3 <br /> 6. Street 'Cit <br /> 7. street G Unit <br /> B. Street G <br /> 9. Street city ❑ Unit 5 <br /> 10. Stroet � ' <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> ❑ OTHER CLEANUP SITE(NON-LOP) t7 FOOD FACILITY 13 SOLID WASTE VEHICLE <br /> © UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL 4 a DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKNARDIC HEM TOILETS <br /> d TATTOOISODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> Q 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(203)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 laterthan 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 prn 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 /> EHn I8-02-0CS <br />