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.QUIN COUNTYPUBLIC HEALT <br /> DATE RELe VEo SAN ,� EHIYL9�BEq ey � <br /> HVICES <br /> ENVIRONMENTAL HEALTH DIVISION y <br /> 304 EAST WEBER AVENUE,THIRD FLOOR AN1 <br /> R 112000 <br /> STOCKTON CA 95202 <br /> (209)408-3420 r- 1`,T •- -AL CH <br /> PUBLIC rRECORDS RELEASE APPLICATION <br /> APPLICANT <br /> ADDRESS / D (�/ /'� <br /> PHONE <br /> 7 O / FACSIMILE l� L L <br /> TENTATIVE'APPOINTMENT DATE TIME <br /> (Please gimme 7 to 10 business days from date of application selunittal) <br /> HECK BOX TO EXPEDITE REQUE -$00 FEE—REQUEST qI2 CE$$__E/ID,,IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANTS Ilii G� ` (X� �._�_ DATE <br /> PILE ADDRESS 1 <br /> 9 d ve 2 2 <br /> ( no <br /> 77) dZIJ <br /> 3s <br /> as <br /> a � <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY O SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL O DAIRY <br /> HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH In PKG TREATMENT PLANT <br /> ❑ TIERED pERNIYYED FACILITY ❑ MOTEUHOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PEIRCING ❑ POOUSPA ❑ HIND USE APPLICATION SITES <br /> ❑ 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 approprlata 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 fila not retumed 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 $78.00 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 <br /> EH oa 1� otmama <br />