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DATE RECEIVED EHD LOG NUMBER <br /> II7 SAN JOA UIN COUNTY <br /> ENvIRONMENTALHEALTH DEPARtwIENT <br /> SEP 1 2 20 304E Weber Ave 3rd Floor Stockton, CA 95205 <br /> 09) 468-3420 Fax : (209) 464-0138 Web : www.co. sanjoaquin.ca.us/chd15 <br /> I <br /> wIri &&1ENT HEALTH <br /> DFRMIT/SERVICES PU /B'LIC RECORDS RELEASE APPLICATION <br /> APPLICANT: �]Vn i 4 0 0 ` _ BUSINESS/AGENCY: (!f <br /> Or G <br /> ADDRESS: G �✓ s rCr .r ST c>l <br /> PHONE: ZQnnZ54 0 �5I3 FACSIMILE: Z / n 34 <br /> 530 <br /> �jt.vQ`3 <br /> TENTATIVE' APPOINTMENT DATE: �A/� . �eOT / 0 Time: <br /> �J// (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE .REQUEST - 93.00 FEE — REQUEST PROCSSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTDATE ' ci l <br /> Department Use Only <br /> _ - FILE ADDRESS .. UNIT <br /> x 1. Street Z5 75C fr f c ._ Sso a - a )1 _ ❑ Unit 1. <br /> 252 C Afr G <br /> 2. Street .�� <br /> 3. Street Z7 0 1 C Ory <br /> Unit 2 <br /> 4. Street ^0 DI <br /> 6. Street 6 ci _ 1 3 <br /> „I <br /> 7C 6. Street L ` <br /> . n � - Ci . . . <br /> 7. street I . l,✓ city , `� _ . .. . Unit 4 <br /> 61 Street 2 S 1 Cil <br /> 9. Street aty nit 5 <br /> 10. Street _ C ity I" gala <br /> _ 3 : .: y Iq <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES ' 1 <br /> ❑" UNDERGROUND TANK (UST) CLEANUP SITE ,(LOP) . .❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> VfTHER CLEANUP SITE (NOWLOP) ' - " " -❑ FOOD FACILITY- - - " " f3 SOLID WASTE VEHICLE - - - _ <br /> 4d UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL , Cl DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR - ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL - ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOLISPA - ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER (PLEASESPECIFY) <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. 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 reorgad (zed 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. )•w ' i ? r <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES �/ NO � y {REVIEW DATE . <br /> EHD 4"2-006 <br /> /• l / `t Irr � / 1L rl1 fl/� I n �i( J eta✓ - .; s0r / �'L: <br /> ✓l .e' /YllitD G �.,,.n-r7y lib Pry <br />