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SAN ,JOAQUIN COUNTYPUBLIC HEALTH SERVICES �� <br /> ENVIRONMENTAL HEALTH DIVISION 0010 <br /> 304 EAST WEBER AVE14UE, THIRD FLOOR <br /> STOGKTON CA 98202 PF \�/r <br /> (209)468-3420 1i <br /> PUBLIC RECORDS RELEASE APPLICATION CO <br /> r <br /> ArPLiCANT 0- r �JGySFA7 _ BU314aS51AGENCY ie�C60 P, <br /> AnORESS SCij7S 3 <br /> PHONE 10 FACSil'+7ILE 067 <br /> TENTATIVE•APPOU47MENT DATE nme <br /> (P;aase 9140 7 to 14 bu:6r.cs3 days imm date of applicatson suhmlttal) <br /> CHECK BOX TO EXPEDITE REQUEST-$78.00 F&E-REQUIST PROCESSEV IN 3 BUSINESS DAYS <br /> SIGNATURE CP APPLICANT _-- -- DATE 1 6 <br /> FILE ADDRESS <br /> t t Nf <br /> a 10s <br /> LAh 19 <br /> r CA a_ z, n, NS <br /> G N N£ I <br /> �_6�_3 F A�aac <br /> 6 ive�vE. <br /> t 1 N 360 L N0 <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> 0 UNDERGROUND TANK(UST)CLEANUP srm(LOP) C }DOUSING ABATEMENT 9 SOLID WAST FACILITY <br /> 1■ <br /> OTHER CLEANUP$)3E;NON ICP) ❑ FOOD I=AClLiTY 0 SCUD WASTE VEHICLE <br /> IN UNDERGROUND TANK(M0NITORI3vGlREMOVAL) 0 DOG KENNEL ■ DAIRY <br /> 0 HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH m PKG TREATMENT PLANT <br /> 4W TIERED PFKMn-MD FACILITY ❑ MOTELMO TEL i PuLiPER TRUCKlYAR.WCHEN TOILETS <br /> M TAT700(5QDYPEIRCING ❑ POOLISPA 0 LANE) USE APPLICATION SITES <br /> ❑ MEDiCAL WASTE FACILITY 19 PUBLIC WATER SY5TEM 0 OTHER(PLEASE SPECIFY A$OVE) <br /> �- List up to ten addros"s in the space above. Select the typs(s) of files from the list above by checking <br /> the appropriate box(es). At least one file type MUST be selected. Fax to 249 464-013Q Qr mpil to the <br /> address incl$ ated above. <br /> Z EMD will notify the applicant if any EHD files exiaL An appointment for review will be confirmed <br /> approxirnately five business days but no later than ten (10)days after receipt of application. The files <br /> will be hold for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. <br /> 3_ A file that i>: actively heing worked on by =HD statf may not be Irnmndiately available for revievr. A now <br /> appiicatian May be submitted Wh¢n the ft is available. <br /> 4. Any fife not returned in the same condition as released will be reorganized by EHD staff at the expense <br /> of the applicant. FuWr9 file reviews by t.1je same applicant,may require a $78.00 depOSit prior to review. <br /> `TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications recelve-d after 3.00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE � TIME <br /> I <br /> i <br /> [SATE CONFIRMED PHONE FAX INITIALS � <br /> REVIEWED YES NO REVIEW DATE <br /> M 00 74 oUo i':O <br /> TDI H.02 <br />