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u i y wu�uJ A 1•,c 1 nl'A r M1U4 I 1 LWI L[1S:NUMUkN <br /> IIS UASE FEG tIVL'0 '� ES -- <br /> SAN JOA'�� COUNTYPUBLIC HEALTH Sk i j � Fr <br /> ' ENVIRONM>=NTAL HEALTH DIVISION �l �� T. <br /> ls,,l� '` <br /> 304 EAST WEBER AVENUE.,THIRD 'FLOOR II//��� � �',': � I�14U, <br /> STOCKTON CA 952t]2 lV l' <br /> (209) 468-3420 Apk 0 9960 <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> iIi �llai�jEN!'hi.. 1-iEALTl-i � <br /> I <br /> BIISINESSIAGENCY L , rr]� <br /> APPLICANT CA ` 1�9�`f <br /> !! <br /> ADDRESS `I ¢f'6 hr� <br /> I <br /> 13 L� FACS]MILE L� R `� <br />`. PHONE- .�/'��� nn <br /> II g r-�-000 TIME <br /> TENTATIVE" APPOINTMENT DATEI <br /> (Please give 7 to 10 business days from date.,appiical lan submittal) <br />' I <br /> CHECK BOX TO EXPEDITE'REQUEST $713.00 FEE-R EST PROCESSED IN 3 SUSlNESS'DAYS / <br /> DATE <br /> I <br /> SIGNATURE OF APPLICANT <br /> i FILE D SS T , <br /> 7T:_1 <br /> - <br /> iy I,c?, eVe r--`- t <br /> �� <br /> �! Lta Acv. y <br /> -50 <br /> ENVIRONMENTAL HEALTH [DIVISION FILES <br /> ❑ HOUSING ABATEMENT SOLID WASTE FACILITY <br /> ( <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ SOLID WASTE VEHICLE <br /> + OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY 0 DAIRY <br /> { UNDERGROUND TANK(M )NITORlNGIREMOVAL) 0 DOG KENNEL CI PKG TREATMENT PLANT <br /> HAZARDOUS WASTE,GI_14ERATOR ❑ CHICKEN RANCH C1 PUMPER TRUCIVYARDICHEM TOILETS <br /> ❑ TiERED PERMITTED FACILITY ❑ MOTEUHOTEL ❑ LAND USE APPLICATION SITES <br /> + 0 TATTOO/BODY PEIRCING d POOLlSPA M OTHER(PLEASE SPECIFY ABOVE) <br /> ❑ MEDICAL WASTE FACILITY ❑ PUBt-iC WATER SYSTEM <br /> t 1. List tap to;tan laddresses 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 t <br /> addre s Indicated above, <br /> 2. EHD will notify the applicant if any EHD files exist. An appointment for review will be confirmed <br /> I approximately five business days but no later than ten (10) days after receipt of application. The files <br /> will be hold for a maximum of five business days for review. Appointments should be scheduled <br /> accordingly. I, <br /> 3. A file that is actively being worked on by EHD staff may not be immediately available for review. A new <br /> application rri,ay be submitted when the file is available. <br /> I 4, Any file lzot returned in the same condition as released will be reorganized by EHD staff at the expense <br /> I of the applicant. Future file reviews by the same applicant may require a �78A0 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 /> i <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED <br /> PHONE FAX INITIALS — <br /> REVIEWED YES NO REVIEW DATE <br /> £H q0t♦ C7/0 00 <br /> 2-100 <br /> . J r t� .DLJc-o� <br /> I t TOTRL P.2-102 <br /> - _ <br />