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DA-i E RECEIVEDLHtI LUL;NUNIOLR <br /> SAN JOAQUIN COUN'T'Y <br /> EN ,�tONMENTAL HEALTH DEPART'r7tN-T <br /> pq�F, Wcbcr Ave 3r`' Floor Stockton, CA 95205 <br /> �I I <br /> ak: (209) 464-013S Web: www.co.san-joayuin.ca.us/chd <br /> AL$G RECORDS RELEASE APPLICATION__ <br /> APPLICANT: J—�n`Q( I BUSINESS/AGENNCY: <br /> �t°�Y �'� ,,/ <br /> r ��� !^GAG P`1 e"% C, . <br /> ADDRESS: 7 <br /> Q ^� �j <br /> PHONE: I — /r,2^ ��6 FACSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> L1 CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PR CESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICAN� �'//?��lc?<�1 ` , �L��� DATE //-2 0 - (73 <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> Dnr 01y <br /> 2. street P�/ O 0 cit ❑ Unit 1 <br /> 3, Street Ol <br /> Unit 2 <br /> d Street % � <br /> s street Ca <br /> � ! r�r �a+r ❑ Unit 3 <br /> 6. Slrcrl COY <br /> 7, st,cel Cd <br /> ❑ Unit 4 <br /> B. Streel pl <br /> 7. strect -_-_-_ Cdy <br /> 10. Streel GI V <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES �OO ���7 <br /> ❑ UNDERGROUND TANK(UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> El 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/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOUSPA ❑ 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 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 /> 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 /> 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 /> �• '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 /> :HD 48.02-006 � <br /> s;tuzoo� II-�i.'-G%: L� Sr.:. .��• f'�t.�:.�'l �it-�•�Il� -- __ _ __ <br />