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DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY - <br /> r _ ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3`d Floor Stockton, CA 95205 <br /> [)E �209)468-3420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: R"11,10 G l..f�t'I— USINESSIAGENCY: A 1✓C'e` t'�'� 11Y!t <br /> ADDRESS: I A Gr d I' %` 4e 5�0r_hojn., <br /> PHONE: Caa�t� �`" `� t 7 FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> El CHECK BOX TO EXPEDITE REQUE $93.00 FEE-REQUE SSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 1. Street G v o � ❑ Unit 1 <br /> 2. Street City <br /> SUed cjty ❑ Unit 2 <br /> 4. Street oty <br /> S. street atyUnit 3 <br /> 6. Street otyTTT <br /> 7. Street Gty Unit 4 <br /> 8. Street City <br /> 9. Street Ci n1 <br /> 10. Street ci <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ,FT UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> 91'OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> PS UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL Cl DAIRY <br /> 1r HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> j-TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOL/SPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILfrY ❑ OTHER(PLEASE SPECIFY) <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 appy:priate box(es). At least one file type MUST be selected. Fax to(209)464-0138 or mail 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 /> 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. A new <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 /> CONFIRMED APPOINTMENT.DATE <br /> TIME p <br /> DATE CONFIRMED `PHONE FAX. INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 4642-006 - <br /> 81=003 <br />