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01/14/2005 09:46 FAX 209 9480(` 0002/002 <br /> wow yr <br /> RECEIVED <br /> SAN J"OAQUIN COUNTY <br /> COWED ENVM0"Mr TAL RE,&LT I)EPARTMEr T <br /> 304 E Weber Ave 3d Floor Stockton;CA 95205 <br /> j OPR1469-3420 Fax: (209)464-0138 Web: NvvAy.co.san-j'oaqwamus/ehd 007 <br /> ENVIRONMENT HEALTH pUBLIC RECORDS RELEASE APPLICA.MN <br /> APPLICANT: BUSINESSIAGENCY: <br /> ADDRESS: a� ti<11�1c-tlt, 3-eQ�e s CIA SS!�C' <br /> PHONE: FACSIMILE: aL'l, <br /> TENTATM*APPOINTMENT DATE: of Time: 1aZ:ao <br /> (Please allow 10 husiness days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-;93,00 FEE--REQUEST PROCESSED IN 3 EU$INESS DAYS , <br /> SIGNATURE OF APPLICANT �Ecraf�t5►�� DATE I �_ <br /> Depar4nent Use Only <br /> FILE ADDRESS UNIT <br /> ❑ ' Unit 1 <br /> z St- l c r < /91� V.Unit 2 <br /> �,U(` <br /> 4. s (a <br /> City �' 71, 6 <br /> I' <br /> s. spa <br /> 6. s+nec 1-0 1 nv aty <br /> 7- So-eel v <br /> City " 1, Unit 4 <br /> e. sum <br /> s, s ❑ Unit 5 <br /> a <br /> ty <br /> 'ENVIRONMENTAL HEALTH DEPARTMENT FILES �A <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 15L SOLID WAS ILIT'Y <br /> OTHER CLEANUP SITE(NON-LOP) d FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> 191, UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL. fg-DAIRY <br /> +� HAZARDOUS WASTE GENERATOR d MICYr--N RANCH C?-PKG TREATMENT PLANT <br /> C3 TIERED PERMnTEO FACILITY ❑ MOTF-L 40TF-L ❑ PUMPER TRUCK/YARD/CH9M TOIL ETS <br /> ❑ TATTOOM00Y PIERCING ❑ POOUSPA LAND USE A!'PLICATION SrfES <br /> ❑ MEDICAL WASTE FACILITY d OTH5R(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. EH17 will notify the applicant if any F-HO 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 1_HO staff may not be immediately available for review. A new <br /> application may be submitted when the file is available. <br /> Q. 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 /> 6. Applications received after 3.00 pm will.be processed the next business day, <br /> TIME <br /> G4HF�fM � aPPY. <br /> olrri i�iENr :.�,' al..J, ':::r .1.1• <br /> :. l I,PHONE . FAX'' �;�':°'Hltlrf(A1:S' ;YJ. <br /> -,DATE.G.ONFI�tM�Ed :l .i' - .. : . <br /> Fti;VlE1NED <br /> TE; <br /> YES NO REVIEW DA <br /> ' EHo�-02-000 <br />