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^`UATP RECESYF_l] <br /> t � 4Fiu L�u titJr...v:: <br /> ` ,. SAN 4�AQUIN COUNTYPU13UC HEALTH 1VICES <br /> �xENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE,THIRD FLOOR <br /> STaCKTON CA 95202 <br /> (209)488-3420 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT I BUSINESS/AGENCY + <br /> Ij <br /> ADDRESS 2 r� G) <br /> PHONE (4P09) 7 k 7 1i 047/0 FACSIMILE <br /> J TENTATIVE'a,PPoIr�Tr�> NT ngTF !2 d✓�C+► �$ ZW I -- -n E _��' A� _. <br /> (Fle:�ca giu8 7 to 1 n bUSIMA55 days from date of application submittal) <br /> 5 UIU17,5 —e, Ll <br /> CHECK BOX TO EXPEDITE RERUE 76 FEE- ED ESr PRQCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT fr, DATE ��.deXAgk ZM1 <br /> Y <br /> FILE ADDRESS <br /> k <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 0 HOUSSI G ABATEMENT C3 SOLID WASTI=FACILITY <br /> ETHER CLEANUP SITE(NON-LOP) 0 FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(Md NITORINGIREMOVAL) 0 DOG KENNEL . 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH 0 PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY 0 MOTE0110111EL 0 PUMPER TRUCKIYARAICHEM-TOu-�rS <br /> TATTOO/BODY PEIRCING <br /> 0 PtlGU$PA 0 LAND USE APPLICATION SITES <br /> 0 fhEDICAL WASTE FAGILnY 0 PUPLIC IfvATER SYSTEM 0 OTHER TLEASE SPECIFY A13011t=} <br /> 1. List up to ton addresses in the space above. Select the type(s) of Iles from the list above by cheCking <br /> the appropriate box(es)= At least one file type MUST be selected, Fax to (209) 4§4.0138 or mail to the. . <br /> address Indicated above. <br /> 2. EMD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> approximately live 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-warked on by EHb staff may not be immediately available for review. A new <br /> application may be submitted when the file is available. <br /> 4. Any 1110 not returned in the some condition as released will be reorganized by EHD staff at the expense <br /> of the applicant- Future file ruvlews by the same applicant may require a$78.00 deposit prier to review. <br /> 5. 'TENTATIVE appointment,dates must be rctorifirrned with EHD staff. <br /> 8. Applications recelved after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME - - <br /> DATE CONFIRMED PHONE FAX IhItTIAI 5 <br /> REVl 11;U YES NO REVIEW DATE <br /> EK as u avustvo <br /> I! <br />