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I <br /> END LOG NUMBER <br /> DATE RECEIVEp SAN JOAQUIN COUNTY <br /> - - ENVIRONMENTAL HEALTH DEPARTMENT <br /> 0 C T 2 '7 Ldd 304 E Weber Ave 3rd Floor-Stockton,CA 95205 <br /> [., -(209)468-3420 Fax: (209)464-0138 Web:www.co.san joaquin.ca.us/ehd <br /> Zoq <br /> E.���11r�j k 1 <br /> ;' S 1=7S PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: BUSINESS/AGENCY: <br /> ADDRESS:J�IZILP <br /> PHONE:�+�!"�3" Z` FACSIMILE.,_i-� <br /> TENTATIVE`APPOINTMENT DATE. Time: <br /> (Please allow 40 business days from date of application submittal) <br /> Q CHECK BOX TO EXPEDITE R kfES - E--R ROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICAN Department Use Only <br /> U141T <br /> FILE ADDRESS <br /> a <br /> f j Unit 1 <br /> F2- <br /> to street Unit2 <br /> Street l� <br /> G <br /> 4. Street <br /> C2 Unit 3 <br /> 5. street <br /> G <br /> s. street U <br /> 7. street <br /> C;iy <br /> 8. street Unit 5 <br /> Ci <br /> 9. Skeet <br /> Ci <br /> 16. street <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> / ❑ USING ABATEMENT ❑ SOLID WASTE FACILITY <br /> Qf�NDERGROUND TANK(UST)CLEANUP SITE(LOP) USING <br /> FACILITY ❑ SOLID WASTE VEHICLE <br /> Q OTHER CLEANUP SITE(NON-LOP) ��p FOOD <br /> KENNEL ❑ DAIRY <br /> Gd DERGROUND TANK(MONITORING/REMOVAL) ❑ DO CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> Ir��AZARDOUS WASTE GENERATOR ❑ CHICKEN RAN ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> 1p TIERED PERMITTED FACILITY ❑ MoTELf PA L.AND USE APPLICATION SITES <br /> ❑ TATTOOIBODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> 13 MEDICAL WASTE FACILITY <br /> �, 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 mail to the <br /> address indicated above. ointrnent.for review will be confirmed <br /> 2. EHD will notify the applicant If any EHD files exist. An app <br /> approximately five business days but no later than ten(10)days after <br /> rdreceipt <br /> cies should li stion. a les <br /> will be held for a maximum of five business days for review. App <br /> accordingly. y g EHD staff may not be immediately available for review. A new <br /> 3. A file that is active) being worked on by <br /> application may be submitted when the file is available. at the expense <br /> 4. Any file not returnee use file reviews bythe same tion as released Vill be the same applicant may requireZed by a$93.00Hdeposit prior to review.of the applicant. F <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 /> CONFIRMED APPOINTMENT_DATA "GIME <br /> DATE CONFIRMED <br /> Y `PHONE FAX ,aNITIAL S', <br /> REVIEW DATE <br /> REVIEWED <br /> YES NO <br />