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DA-i E RECEIVED SAN JOAQUIN COUNTY L1 10 LUG NUiolu'Lk <br /> EN ONMENTAL HEALTH DEPARTMENT <br /> Q I t Weber Ave 3`d Floor Stockton, CA 95205 <br /> (209) 464-0138 Web: www.co.san-joaquin.ca.us/c <br /> hd <br /> RECORDS RELEASE APPLICATION <br /> �1 --{ <br /> APPLICANT: Y �YC2 ,J��yP�Y -/ BUSINESS/AGENCY: <br /> ADDRESS: � t' - �}t. �UC,.F'Prl-er' ��L � <br /> PHONE: 001 -72-7— ��6 FACSIMILE: -y- <br /> TENTATIVE`APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-S9 .00 FFEEE---REQUEST PPR CESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT`-!�/Cl/�"?' DATE <br /> Department Use Only <br /> pp FILE ADDRESS UNIT <br /> 1. Street /O O GI E] .1 <br /> Unit 1 <br /> i. Street P'V Cil <br /> J. Street Oly VLUnit 2 <br /> 4. Strcel /�! Cil <br /> ❑ Unit <br /> 6. Slrcel Cil <br /> 7. Slreel 01y ❑ Unit 4 <br /> B. Slreel Cil <br /> 9, Slrcel 611 <br /> 10. Strcel Cn '� <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <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 ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <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 (east 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 reorganized 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. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> 310!]003 I',�r,' L%�� LI !j(;L ���' j�Lr �f / <br />