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Environmental Group 916 18-6688 P• 1 <br /> Oct 29 04 09: 58a R .,v EHD LOG NUMBER <br /> DATE RECEIVED SAN JOAQUIN COUNTY <br /> RONMENTAL HEALTH DEPARTMENT <br /> 3 Weber Ave 3`d Floor Stockton,CA 95205 <br /> 342 ax: (209)464-0138.Web: WWW.cc.san-joaquin.ca.us/ehd <br /> Zoqq <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> � .'- --- BUSINESSIAGENCY: ` <br /> UCAN O C * IT p SA^d OAD�- <br /> FACSIMILE: K <br /> Z' O� 7me: IOD�— <br /> TENTATIVE'APPOINTMENT DATE: ts' <br /> ppII (Please allow 10 business days from date of application submittal) <br /> Yy CHECK BOX TO EXPEDITE REQUEST.$93.00 FEE- U T PROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT Department Use OnlY <br /> UNIT <br /> FILE ADDRESS <br /> � a!y a U ❑ Unit 1 <br /> sveN v a05 <br /> 3 r7OG yl L <br /> x. Sine tit. a .♦✓ _l.'. t`'• 'w ❑ Unit 2 A <br /> 3. se.t d J!'ti�. X9 1\• .... \��O <br /> a. sa«t OSI, <br /> an •`'C,� <br /> a <br /> 6 sv.d Unit <br /> ,. Street Cil <br /> a. steer 3 a nit 5 <br /> 10. Street 21 • S G1L+E't117 -'r• <br /> 5 . }L2 µ'ENVIRO�pgENTAL HEALTH DEPARTMENT FILES <br /> ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> 19 UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> 10 OTHER CLEANUP SITE(NON-LOP) ❑ DOG KENNEL ❑ DAIRY <br /> IE UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ CHICKEN RANCH Cl PKG TREATMENT PLANT <br /> III HAZARDOUS WASTE GENERATOR ❑ MOTEUHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> is TIERED PERMITTED FACILITY ❑ pooUSPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOn3oDY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <br /> 1. List up to ten addresses in the space above. <br /> ry�USTlect the <br /> be selected f Fax to f209)464-0138from the list vorbmailchecking <br /> the appropriate box(es). At least one file type <br /> address indic�ed abpove.- ointment for review will be confirmed <br /> 2, EHD will notify thea applicant if any EHD files exist. An app application. The files <br /> approximately five business days but no later than ten(10)days after receipt of <br /> um of five business days for review. Appointments should be scheduled <br /> will be held for a maxim <br /> accordingly. <br /> 3. A rile that is actively being worked on by EHD staff may not be immediately available for review. neral <br /> application may be submitted when the file is available. at the <br /> 4, Any file not returned in the same condition same applicant as s i may require a$93.00 depobe reorganized by EHO sit staff prior to review. <br /> of the applicant. Future file reviews by <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> g Applications received after 3:00 pm will be processed the next business day. <br /> TIME <br /> CONFIRMED APPOINTMENT DATE INITIALS <br /> PHONE FAX <br /> DATE CONFIRMED REVIEW DATE <br /> REVIEWED YES NO <br /> eno�e-0zooe . <br /> ereaam <br />