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bAN JOAQUI.N C.UUN-1-X <br /> U—MONMENTAL HEALTH DEPAT--4ENT <br /> 4 E Weber Ave P Floor Stockton, CA*205 <br /> MAR 1 9 21 69)468-3420 Fax: (209)464-0138 Web:www.co.san joaquin.ca.us/ehd <br /> ENVIRONMENT Q1rPQHEALTH PLIC RECORDS RELEASE APPLICATION <br /> APPLICANT. W A1C 0 C BUSINESSIAGENCY: <br /> f' [sox 13 44 t~ f,� �� !�E-A/1 <br /> ADDRESS: <br /> PRONE: FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> NOW 10 business days from date of application submitt4 s <br /> CHECK BOX TO EXPEDITE REQUEST-;93 F — QU PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 3 - <br /> Deparinmt Use Only <br /> FILE ADDRESS UNIT <br /> /Ir�oEg4--,4, JZ CRY .4CAt tlo <br /> 2. She 14 IL-0 E J JAJ 000 64 r Ddb City AC,-4,--&-e-40 ❑ Unit i <br /> a S%Md <br /> iy0 3� <. Sh ❑ Unit 2 -Q� <br /> i5 d a¢ cit <br /> S. sem <br /> s. Seed Unit 3 <br /> 7. scea . <br /> a. stem City Unit r <br /> 9. 55ed <br /> io. seeet Unit 5 <br /> City <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOPEHOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) /�FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL ❑ DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY 13 MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTOOA30DY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> 1. List up to ten addresses in the space above. Select the type(s)of files from the list aboye by checking f <br /> the appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138 or mall 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 Af?AQINTMENTDATE. ., IME <br /> Y <br /> DATE GQNFIRMED - PHONE FAX-`--'""- _'-- INITIALS <br /> 4- - <br /> 1fZEY11=WED YES NO REVIEW DATE >, <br /> EHD".024M <br /> eroraoas - <br />