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� - I# EHD LOG NUMBER ) <br /> SAN JOAQ <br /> UIN COUNTY � <br /> " ENVIRONMENTAL HEALTH D EPARTMENT <br /> 304 E Weber Ave 3rd Floor Stockton,'3CA 95205 <br /> (209) 468-3420 Fax: (209)464-0138 Web:www•co.s�an-joaquin.ca.uslehd <br /> PUBLIC RECORDS RELEASE APPLICATION; „ <br /> APPLICANT.ooi „---_ BUSINESSIAGENCY: III <br /> - <br /> . �t I <br /> ADDRESS: <br /> PHONE: 3 7 f — O 3 7 f! <br /> FACSIMILE: i� y <br /> TENTATIVE*APPOINTMENT DATE: <br /> I� 'r <br /> (Please allow 10 business days from[tate of application submMal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSED 1N 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT PATE <br /> } Department Use Only <br /> FILE ADDRESS UNIT <br /> ,1 ` ❑ <br /> 1. Street a Unit 1;'I <br /> z. street <br /> 3. Strut <br /> City o ❑ Unit 2 <br /> �I <br /> 4. Street aty <br /> 5. Srreel C` ! <br /> s. street CAY <br /> cay7. street <br /> �+ Unit 4 <br /> Ow <br /> B. StreN <br /> 9. Streetaty <br /> 10. sveet <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENTJ ❑ SOLID WASTE FACILITY <br /> 11 SOLID <br /> E3 OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY �} ❑ DAIRY WASTE VEHICLE <br /> C3 UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL <br /> ❑ HAZARDOUS WASTE GENERATOR 11CHICKEN RANCH I , ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKrYARDICHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACIL"Y ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to tett addresses in the space above. Select the4ype (s)of files from the list above y checking <br /> the appropriate box(es). At least one file type MUST be selected lI Fax to 209 464-0138 or mail to the <br /> address indicated above. I iM <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 (10.1 <br /> daysl�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 /> Il '' <br /> -%CONFIRMED AP-P'. -- NT.-DATE TIME a <br /> DATE CONFIRMED. PHONE '} FAX INlYIALS '. <br /> 'REVIEWED YES NO REVIEW DATE. . <br /> EHA<8N2-006 I{ <br /> .._xrttrtooa- _ <br />