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09/17/2003 09:36 FAX 209 94-80621 f7j002/004 <br /> DATE RECErvEO �✓ �►, 1 <br /> ENO LOG NUM MER <br /> �- SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION- <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> S E P 1 7 2003 STOCKTON CA 95202 14q7 <br /> (209)468'3420 <br /> '�r��,ijNMENT HPr-C USLIC RECORDS RELEASE APPLICATION <br /> v 1-i % - <br /> 11 <br /> APPLICANT _\j t �:J_ BUSINES5/AGENCY �l-F,�( FrCLZ <br /> ADDRESS <br /> PHONE 201 I Ci Lt )l 13 LI s FACSIMILE "-79 NE S�U 6 2-I <br /> TENTATIVE*APPOINTMENT DATE -( /Zf4- 0 3 TIME Zcio <br /> (Please give 7 to t0 pu tress days from date of application submittal) <br /> CHECK BOX TO EXPEDFTE REQUEST•$ 7.00 F —R$QUEST PROCESSED IN 3 BUSINESS DAYS , <br /> SIGNATURE OF APPLICANT DATE <br /> FILE ADDRESS THIS SIDE EHD STAPF USE ONLY I l <br /> PROGRAM ELEMENTS SEARCH <br /> 3 I �d QC CA 3 <br /> 2 '2 CA 1 Pr 1• L, 3 <br /> L ,..l E AJf. I <br /> rA c' c1 S�. ( r ►� <br /> Ir <br /> ID 5f0 <br /> LIAJO <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> M UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 01 SOLID WASTE FACILITY <br /> R OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SCUD WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL 0a DAIRY <br /> KAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH IR PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELlHOTEL ❑ PUMPER TRUCk/YARD/CHEM TOILETS <br /> ❑ TATTOOlBODY PEIRCING a•PdOLISPA • ' ga'LAND USE APPLICATION sFrES <br /> ❑ MEDICAL WASTE FACILrTY ❑ PUBLIC WATER SYSTEM 17 OTHER(PLEASE SPECIFY ABOVE) <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. 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 fora 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$87.00 deposit prior to review. <br /> 5. "TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Appilcatlons 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 />