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03/18/2005 11:59 FAX 209 948"^,?1 ; Q002 <br /> TE RECEIVED <br /> SAN J04Qvuv Comet <br /> ,o E ED ENIMaN-NiE YTA LHEALTH DEPAPTIYMNT _ <br /> 304 E Weber Ave 3 Floor Stockton;CA.95205 <br /> .464-0138 Web:www.co-=ioaquin_ca uslehd <br /> V,AR <br /> ������8-3420 Fax: {209� <br /> �[Vsflmvk � �-TfUELIC RECORDS RELEASE AYPLICAMON <br /> APPWCANT:� -_lb��g, 8t7S1NES5lAGEIICY: <br /> l� ADDRESS: ,S <br /> PHONC-:_ IDGI� +� FACSIMILE: If <br /> TENTATIVE'APPOINTMENT DATE <br /> {Please allow 10 business days from date of application submittal} <br /> i <br /> CHECK BOX TO ECpwm Rz(auEST-Pa_ao FEE REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT 7 DATE <br /> pepartmentusa only <br /> Z kP z �ozo-$ LE ADDRESS UNIT <br /> 1 2• WedG - <br /> 4Cl r 'r` flit Z <br /> rr,a. sit O � t :59oe <br /> � <br /> _ pre <br /> s. s,ree ` .`4`Y }^r`.' .. flit 3 <br /> •-=r , <br /> T � _ � nit 4 • . <br />{ ❑ Unit 5 <br /> 9. Street <br /> SON <br /> L <br /> -ENVIRONMENTAL}i�.TH 0EPARTMENT F1LE5 ' �' r <br /> UNDERGROUND TRK(UST)CLEANUP SITE lt,oP) l� HOUSING aBATEMENT w.souo wAsTE FACILMY <br /> C�4 O'niER CI.P-Mup 5rM(KON-Lop) 0 FOOD FACILIT7 Q SOt 101rvPSTE V>wH1GL>" <br /> Z UH0ERGROUND TANK(MONrrORINCVK8?d0VAL) a DOG KENNEL EL DAIRY <br /> ffi t{AZARD6US WASTE GENERATOR 13 CHICKEN RANCH ®-PKG TREATMENT PLANT <br /> C3 T1ERE.D PER1VIaT'ED FAciu v 0 MOTELAiOTEL E, PUMPERTRUCKryAR[)jCHEMT0ILM <br /> ❑ TATTOOISODY PIERCING La POOLISPA 5L LAND US>=APPLICA.TION'SITES <br /> 11 MEDICAL WASTE FACILITY [7 OTHER(PLEASE SPECIFY} <br /> 1. List up to ten addresses in the space above. Select the type(s) of files from the list abaft:,by checkinc <br /> i the appropriate boxes)_ At least aria file type MUST be selected.. Fax to 209 464-0i 3S or mail to the <br /> ! address.indica ted above. <br /> 2. EHD will nati•fy the applicant d any EHO files exist An appointment For reVIOW will }ae con'firmed <br /> approximately five business days tkit-no later than ten (10) days after receipt of application. The Nes <br /> will he hell 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 Far review, Ane <br /> application may be submitted when the file is available. <br /> 4. Any dile not returned in the same condition as released will be reorganized by EHD staff At the expen! <br /> of the applicant. Future file reviews by the same applicant may require a$93,00 deposit prior fo reVit <br /> S. *TENTATIVE appointment dates must be confirmed with EHD staff. <br /> Applications received'after3:00 pm Will-be processed the Ilaxtbusiness stay. 4 <br /> � �7I!lF•:�RMU:APPQINTM>=NT'i]Ai `FkME ,.{r <br /> CAAT�: ,QNFi�MEI ,~ a:,' YPHQNl;'. HFXIAZ: <br /> .: <br /> REVIEWED YES NO REVIEW DATE.j. <br /> _ �� <br />