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©9:32 D9- 2225 MODESTD ATC • PAGE 01 <br /> opq\� EHD LOG NUMB[ <br /> �,� jH D SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> NOV 0 2 2004 304 <br /> 468-3420 304 E Weber Ave P Floor Stockton, CA 95205 <br /> ENVIRONMENT HEMI H Fax: (209)464-0138 Web:www.co.san-joaquin.ca.us/ehd <br /> PERMIT/SER`VIC'ES^ PUBLIC RECORDS RELEASE APPLICATION {QA <br /> APPLICANT: JGI'V 1 �r 0'n BUSINESSIAGENCY C' 1 - ' <br /> --'i QrA, UAYC. �t R 9 - <br /> ADORESS: ( I I I )- ane' <br /> PHONE: <br /> �G' i FACSIMILE: <br /> TENTATIVE'APPOINTMENT DATE: O f 4 f DLI Time: <br /> (Please allow 1D business days from date of appllcatlon submittal) <br /> CHECK BOX TO EXPEDITE REQ ST-$ .00 FEE- QU PROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT Department Use OnIv <br /> UNIT <br /> FILE ADDRESS <br /> E] Unit 1 \ '� <br /> ,. stiKi S O G r' a � <br /> 2. Sv � city Unft 2 N <br /> 3. 3"0 <br /> aty <br /> CKY e. se U <br /> 5. SlreN <br /> a <br /> as^ aty Unit 4 <br /> ste <br /> aty <br /> e. $1.t aty Unit 5 <br /> 9. SVM <br /> 10. $VOGI <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> 13DERGROUND TANK(UST)CLEANUP SITE(LOP) FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> ) o�H ER CLEANUP SITE(NON-LOP) C] DOG KENNEL ❑ DAIRY <br /> OERGROUND TANK(MONITORING/REMOVAL) ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> HAZ <br /> H_AZARDOUS WASTE GENERATOR ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> IERED PERMITTED FACILITY ❑ pOOUSPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOBODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <br /> ypes)of Tiles from the list above by checking <br /> 1. List up to ten addresses in the space above. Select the t <br /> the appropriate box(es). At least one file type MUST be selected. Fax to (2091 464-0138 or mail to the <br /> address Indicated above. ointment for review will be confirmed <br /> 2. EHD will noti theapplicant if any EHD files exist An appointment <br /> approximately five business days but no later than <br /> an ten(10} days after ntments shou dpbe schedu edftles <br /> will be held for a Maximum of five business da s for review. App <br /> accordingly- <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A nev <br /> application may be submitted when the file is available. at the expens( <br /> e me 4 oAny f thele not returned <br /> in th file eviews bytthe same applicantion as released may e squire a $93.00 depobe rorganized by EHD staff priori to eviev <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 TIME <br /> DATE CONFIRMED <br /> PHONE FAX INITIALS <br /> REVIEWED - YES <br /> NO REVIEW DATE <br /> EHo se-o2406 <br /> em s <br />