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I <br /> SAN JOA JN COUNTYPUBLIC HEALTH SEUCES I <br /> ENVIRONMENTAL HEALTH',DIVISION /j <br /> 304 EAST WEBER AVENUE,THIRD FLOOR JY <br /> STOCKTON CA 95202 , <br /> 'v (209) 4613-3420 <br /> P_U_BLIC RECORDS RELEASE'APPLICATION <br /> APPLICANT 11I J t ""� ""�`I` 1 ``'" ` BUSINESSIAGENCY <br /> ADDRESS L\�} \-��vn M-pC9SS�c 1pCA <br /> PHONE 1✓ZZ( FACSIMILE <br /> TENTATIVE"APPOINTMENT DATE TIME <br /> (Please Oiye 7 to lt)business days from dale orapplication submittal) <br /> CHECK BOX TO,EXPEDITE REQUEST-$07.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> FILL"ADDRE=SS THIS SIDE EHD STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH <br /> - <br /> �`S3 <br /> z3 o p CJA_ L` AV-t <br /> I 'i d 3 3 s 4.fl�s IA.rL . <br /> I <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP). ❑ HOUSING ABATEMENT ❑ SOLID WASTE r-ACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ) ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL' - ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOOIBODY P41RCING ❑ POOIJSPA ❑ LAND USE APPLICATION SITES <br /> 11 ❑ MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Select the types) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be.sclected. Fax to (209) 464-0130 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 reorganized by EHD staff at the expense <br /> of the applicant. Futurc file reviews by the same applicant may require a $07.00 deposit prior to review. <br /> 5. "TENTAT.fVE 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 /> 00 14 <br /> 00 <br />