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►SAN JUAIQU1N LUUNFY <br /> EN-�RONMENTAL HEALTH DEPARTS-NT <br /> Weber Ave 3`a Floor Stockton,CA 95 <br /> 5_Z(fg�9)468-3420 Fax: (209)464-0138 Web:www.co.san-joaquin.caus/ehd <br /> 7 <br /> HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT:}SfP..i�G BIJSIN>=SSlAGENCY: <br /> E (� <br /> ADDRESS: ^t'Y! GtJ s Y z' � b FfuL S� -- <br /> PHONE: ✓�� C� � �'l1G +FACSIMILE: �30���6 -600 5- <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> .i <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—KL,%d3JEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> ❑ Unit 1 N <br /> unt 2 <br /> 4. s M � facy f ?j <br /> 3 <br /> V19sk-d <br /> d�� — — Unit 3 <br /> ci1 (0 <br /> v- <br /> el Unit 4 W ; unit 5 S� i <br /> ! <br /> 10. <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES77 - <br /> .- `:N�, .> s16 Fal f <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) 13HOUSING ABATEMENT 13SOLID WASTE FACILR j <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR O CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMfTTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARD"EM TOILETS <br /> ❑ TArTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) 1 <br /> i, Ust up to ten addresses in the space above. Select the typo(s)of files from the list above by checking i <br /> the appropriate box(es). At least one file type MAST be selected. Fax to(209)45.4-0138 or mail to the <br /> address indicated above. <br /> 2. EHD will notify the applicaint 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 revlew: 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 da ,. 77- <br /> .0 <br /> , £ <br /> C4.NFLRMED. <br /> APP6INTM5NTDATE. :r z .-TIME <br /> DATE CONFIRMED,_ _ :PHONE FAX'" _ tNITlA15 3 <br /> 'FtEVIEWED YES NO REVIEW DATE <br /> EHO 46-02-006 <br /> &MP2003 <br />