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0,,i-Ita,;L;VLU i` �,'� LIitJ Lv.f+'v LlullC <br /> '�'-F_�AN JOA )N COUNTYPUBLIC HEALTH SE-ACES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> � � 4 Liil11 i 304 EAST WEBER AVENUE, THIRD FLOOR <br /> STOCKTON CA 95202 1 <br /> ori V IRON1U EN T HEALTH (209) 468-3420 <br /> PERMIT/SERVICES PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT BUSINESSIAGENCY <br /> E ADDRESS .Q .. Box 3 � � ���L M IS-30Z <br /> f <br /> PHONE FACSIMILE <br /> TENTATIVE*APPOINTMENT DATE TIME <br /> (Please give 7 to 10 business days from date of application submittal) N <br /> CHECK BOX TO EXPEDITE REQUEST- 7.00 FE1=— T PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT " DATE � <br /> FILE ADDRESS THIS SIDE EHD STAFF USE ONLY <br /> E PROGRAM ELEMENTS SEARCH <br /> o a ✓E - ram c a 9. � IM <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> lid UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> Cl OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> ❑ UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL d DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELHOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOOIBODY PEIRCING ❑ POOLJSPA fa LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <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 appropriate 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 $87.00 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 TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE I`( <br /> EK 00 14 08101100 <br />