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06/15/2004 09:44 2099314743 WATERLOO SHELL PAGE 01 <br /> EHD LOG NUMBER <br /> DATE RECENED SAN JOAQUIN COUNTY <br /> tilt L��!'=�ill`l°r �� � ENV)(RONmENTA.L HEALTH DEPARTMENT Q <br /> 304 E Weber Ave 3`d Floor Stockton,CA 95205 <br /> U U N 1 5 2@M)468-3420 Fax: (209)464-0)38 Web:www.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT' <br /> BUSiNE8$fAGENCY: O <br /> df <br /> ADDRESS: . <br /> PHONE: c:�I—A f. - FACSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: Tim: <br /> (Plans*allow 10 busintss days from daft of application submittal) <br /> ❑ CHECK BOX TO EXPEDITE REQU T.$9 EE—RE ROCS D IN S BUSINESS DAYS <br /> SIGNATURE OF APPLICANT <br /> DATE � l' <br /> Department use my <br /> UNIT <br /> FILE ADDRESS <br /> unit 1 1�v� <br /> [2. � -a" <br /> 1. s..+ ❑ Unit.2 <br /> A. Street V <br /> 6 street Unit 3 <br /> s. sweet � - <br /> Unit 4 <br /> 7. S"w _EM . <br /> B. SVeel <br /> ❑city <br /> Unit 5 <br /> 8. 9traa <br /> 10. SO-1 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) O HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> ❑ FOOD FACILITY <br /> in SOLID WASTE VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) O DOG KENNEL Q DAIRY <br /> UNDERGROUND TANK(INIONITORINGIREMOVAL) 0 CHICKEN RANCH G PKG TREATMENT PLANT <br /> O HAZARDOUS WASTE GENERATOR MOTELIHOTEL O PUMPER TRUCKIYARDIGHEM TOILETS <br /> o TIERED PERMITTED FACILITY O LAND USE APPLICATION SITES <br /> 11TATTOO/BODY PIERCING ❑ POOLtSPA <br /> O MEDICAL WASTE FACILITY ❑ OTHER(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. 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 some applicant may require a$93.00 deposit prior to review. <br /> '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 /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> tiHO�a.o2-0o6 <br /> VW2W2 <br />