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DATE RECEIVED SAN JOAQUIN COUNTY tEFIU LUV NUMBER <br /> i� to IIi,! <br /> -"F C,J�,L� �; ,EN.IRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3rd Floor Stdckton, CA 95205 <br /> OCT - 2 20M9)468-3420 Fax: (209)464-0138 Web: www.co.sanjoaquin.ca.us/ehd <br /> I:AVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> Ur � <br /> APPLICANT: `Sri I'1 � r� _BUSINESSIAGENCY: ��1'1 ;r��E <br /> ADDRESS -7 , (.� N, 4?a r y o f �)V cj �� /Lz/'111�wr4-_ p <br /> 7 <br /> PHONE: i�^� �h 7 FACSIMILE: 0-16) ref <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST•$93.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT /it v�� /L�r �' w��� DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 1. Street ❑ Unit 1 <br /> StreetGt A <br /> 3. street ci ❑ Unit 2 '�1 <br /> cit <br /> a. Street 1� <br /> s. street City Unit 3 <br /> ctt <br /> 6. street <br /> cit Unit 4 <br /> 7. Street <br /> e. sweet <br /> cit <br /> rd ❑ Unit 5 <br /> 9. Streetopm 0 <br /> Cit <br /> 10. Street <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> R UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) <br /> ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE a ❑ DOG KENNEL ❑ DAIRY <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> 1$�HAZARDOUS WASTE GENERATOR ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOO/BODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <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 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. Anew <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 /> —S <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 4"2.006 <br /> W=003 <br />