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SAN JOAQUIN COUNTY <br /> E -� <br /> Er HEALTH DEPARTi+ U - <br /> 304 E Weber Ave 3d Floor Stockton, CA 95205 <br /> (209) 468-3420 Fax: (209).464-0138 Web: www-cO-san-joaquin.ca.us/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION I <br /> APPLICANT:` WCl r <br /> BUSINESS/AGENCY: <br /> ADDRESS:27 /K 6ti <br /> yzS tt3 /F <br /> PHONE: ��� Q rr � <br /> FACSIMILE: <br /> TENTATIVE-APPOINTMENT DATE: <br /> Time:_ <br /> (Please allow 10 business da <br /> ❑ Ys from date of application submitta0 <br /> CHECK Box TO EXPEDITE REQUEST-O �� EE—REQUEST PRO ESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT 7 // c/ <br /> DATE >( L T�G <br /> Department Use only <br /> 3�j,� FILE ADDRESS <br /> D t. Street v2 S" S C u u w77a UNIT <br /> 0. suer ❑ Unit 1 <br /> 4. ssee <br /> S. su< ❑ Unit 2 LAA 1 <br /> � so�et c Unit 3 <br /> Unit 4 <br /> 9. street <br /> 10. $trM <br /> Q ❑ Unit 5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(Lop) ❑ HOUSING ABATEMEN <br /> OTHER CLEANUP SITE(NON-Lop) ❑ T ❑ SOLID WASTE FACILITY <br /> UNDERGROUND TANK(MONITORINGlREMOVAL ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> HAZARDOUS WASTE GENERATOR ) DOG KENNEL C1 DAIRY <br /> FACILITY ❑ C <br /> ❑ TIERED PERMITTED FACILITY RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TATTOOIBODY PIERCING ❑ MOTELIHOTEL 11PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ MEDICAL WASTE FACILITY ❑ POOLISPA 11 LAND USE APPLICATION SITES <br /> ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Sele <br /> the appropriate box(es). At least one file ct the types)of files from the tilt above by checking <br /> address indicated above. type MUST be selected. Fax to(209)464-0138 or mail to the <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 /> S. `TENTATIVE appointment dates must be confirmed with EHD staff. <br /> s• Applications received after 3:00 pm will be processed the next business day. <br /> -CONFIRMED APP61NTM ENT DATE > <br /> _ TIME <br /> DATE CONFIRMED PHONE <br /> FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> - Eno�eazoas <br /> vazaa3 <br />