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SAN JoAQv1N COUNTY <br /> ENV - MENTAL HEALTH D EPARTNIw.IT <br /> �. <br /> I <br /> rd <br /> 304 304 E Weber Ave 3 Floor Stockton,CA 95205 <br /> MAR 3 U 200209)4b8-3420 Fax: (209)464-0138 Web:www.co.san jaaquin.causlehd <br /> "HEALTH PUBLIC,RECORDS RELEASE APPLICATION <br /> .r—• •s s CCM �' <br /> APPLJCAHT. ! BUSINESSIAGENCY: <br /> ADDRESS: <br /> PRONE: FACSIMILE: <br /> TENTATIVE"APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> ❑ CHECK BOX TO EXPEDITE REQUEST'$9 . FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> F <br /> r SIGNATURE OF APPLICANT _ ': .i��!�% DATE <br /> DepatimentUse 0* <br /> UNIT <br /> FILE ADDRESS <br /> ❑ Unit 1' <br /> I saeee <br /> .3. Sbvd ❑ Unit 2 <br /> 4. Shed <br /> s. saes Unit 3 �dy) <br /> 6. Sired <br /> T. Stied Unit 4 <br /> a. sena <br /> citv <br /> S. Sired CAY <br /> ❑ Unit 5 <br /> 10. sweet citv <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(MONITORiNGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR " ❑ CHICKEN RANCH ❑ PKG TREATMEHT PLAN <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY 13 OTHER(PLEASE SPEi:IFY) <br /> 1. List up to ten addresses In the space above. Select the type(s)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 snail 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 /> i 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. Anew <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 /> CNF:RMED AF'PO1NTMirNf 1ATE <br /> i_-TIME <br /> PATE CQCVFIRMED PHOT iE ;FAX iN171AL 5 <br /> RIEMMED YES .`HD REVIEW DATE °: r <br /> EHD 48-OZ6 - <br /> arertaos <br /> i <br /> iI <br />