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1 ' <br /> ' <br /> DATE RECEIVED SAN JOAQUIN COUNTY l.�d <br /> VE0 EHD LOG NUMBER <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> R 304 E Weber Ave 3rd Floor Stockton,CA 95205 <br /> 200 209)_4.68-3420 Fax: (209)464-0138 Web:www.co.san-joaquin.cams/ehd <br /> EN' ;,4ENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> ADPL ICANT':O"1C J2. - 1IL.a BUSINEssIAGENCY: <br /> ADDRESS: -581S s Q e <br /> UX� z"C1C�t"-,? k Cty <br /> PHONE: FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (pique allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> Ll <br /> SIGNATURE OF APPLIC DAT '�S <br /> Depa t use only <br /> FILE ADDRES e-& UNIT <br /> AV sLeei sLS?anc LL-E) R-2eV <br /> r� ❑ Unit 1 <br /> r stred ti� -I 6 2 a LA <br /> z su.d 3 3 }} a'hw PrL "4. Skeet <br /> i Unit 2 <br /> cav <br /> [42 <br /> ❑ Unit 3 raw <br /> Me Unit 4�CKV $ <br /> CRY <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> t UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT 14 SOLID WASTE FACILITY <br /> I OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY I(SOLID WASTE VEHICLE <br /> UNDERGROUND*ARK(MONITOWNGIREMOVAL) ❑ DOG KENNEL D DAIRY <br /> HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH © PKG TREATMENT PLANT <br /> TIERED PERDY <br /> FACILITY 0 MOTELJHOTEL 0 PUMPER TRUCKIYARDICHEM TOILETS <br /> TI <br /> TR D PER Y PIERCING E7 POOLISPA LAND USE APPLICATION SITES <br /> MEDICAL WASTE FACILITY OTHERrLEASE SPECIFY) <br /> List up to ten addresses in the space above,, Select the'type(s)of flies from the list above by checking <br /> the appropriate box(es). At least one file type MUSTIbe selected. Fax to 209 464-0138 or mail to the <br /> address Indicated above. <br /> END will notify the applicant if any EHD files exist. An appointment far review will be confirmed <br /> approximately five business days but no later than ten(10)days afti of should be tion. leThe d will be held for a maximum of five business days for review. Appointments <br /> accordingly. <br /> A file that is actively being worked on by END staff may not be Immediately available for review. A new <br /> plication may be submitted when the file is available. <br /> expense <br /> be reorganized Milat the <br /> e not returned in the same conditiioonn released <br /> d will <br /> may require a 3y OHD stadeposit prior to review• <br /> of the applicant. Future file reviews by same <br /> *TENTATIVE appointment dates must be confirmed with EHD staff. <br /> Applications received after 3:00 pm will be processed the next business day. <br /> MED <br /> :APPOINTMENT DATE <br /> TIME <br /> '.PHONE FAX INITIALS <br /> YES <br /> NO REVIEW DATE <br /> TM 4545M <br /> &SrZN3 <br />