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. t I <br /> EHO LOG Nil ER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 2.005 304 1;Weber Ave P FloorStockton, CA 95205 <br /> 209) 468-3420 hax: (209)464-0138 Web: www.co.san-joaquin.6.i-us/eh <br /> ENVIRONMENT HEA LT� i� I W <br /> -PERMIT/SERVICES PUBLIC RIJCORDS RELEASL APPLI.C.4T1DN <br /> APPLICANT: \`_-C� �_-_,Q- �(r NC_Z BUSINESSIAGENCY: p ][�j�,� d � <br /> ADDRESS: Y'1t'1i1�-#'Y"t- ( a ��€.sk,'` � q_ ----- --- ---- <br /> PHONE: CSIM€LE: <br /> TENTATIVE"APPOINTMENT DATE:, _ Time: <br /> (please allow 10 business days from date of applicallon submittal <br /> CHECK BOx TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT X Jx DATE <br /> Department Use On <br /> 'F <br /> FILE ADORE-15S UNIT <br /> 1- ;tram 3 ) p Unit 11 <br /> 2. Slreel <br /> 3. s+reet > t 3 c7 } ]' d Unit 2 <br /> 4. Slrvvs Cit <br /> 3� <br /> G1 � F� � Un€t 3 <br /> & SVeel �'L CI <br /> fa <br /> 7. slrcet � I' W I i &f##0Un€t4 <br /> 6, 5traer ♦ C l w �� <br /> 9. Streel _ � J?�.}1'� fitly -- f r�1 ' i'i� ❑ Unit 5 <br /> 10. Vfeel — <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> foL UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT d SOLID WASTE FACILITY <br /> V,OTHER CLEANUP SITE(NON-LOP) Or FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> 19L UNDERGROUND TANK(MON ITORINGIREMOVAL) 0 DOG KENNEL ❑ DAIRY <br /> JIL HAZARDOUS WASTE:GENERATOR ❑ CHICKEN RANCH ❑ PKG ITRVATM ENT PLANT <br /> *TIERED PERMITTED FACILITY ❑ MC>TELIHOTEL El PUMPF-R TRUCKIYARDICHEM TOILI <br /> ❑ TATTOO11300Y PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION,SITES <br /> Cl MED€CAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 'i_ hist up to tett addresses in the space above. Select the type(S)of files frpm,the list above by cher} l <br /> the appropriate box(es), At least one file type MUST be selected. Fax to 209 464-0138 or mail to t <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. Tito fi <br /> will be held for a maximum of five business days for review. Appointments'should be scheduled <br /> accordingly. I' <br /> 3. A file that is actively being worked on by EMD staff may not be irnmediately available for review, A v <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 FWD staff at the exp( <br /> of the applicant. Future file reviews by the same applicant may require a'$93-00 deposit prior to re, Y. <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 /> CONFIRMF,D APPOINTMENT DATE - -- _ _-- TIME <br /> DATE CONFIRMED PHONE; FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> cHn�aJ+�nna ��•- -- , <br /> I. <br /> ii <br />