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L. LUUb IU: I IAVI No, 2539 P. 1/2 <br /> DATE RECEIVED EHD LOG NUMBER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 Fast Main Street, Stockton, CA 95202-3029 <br /> E �GC'c Telephone: (209)468-3420 Fax: (209) 464-0138 Web: www.sjgov.or /eh <br /> L-- � <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: knn6 {'y-1 B i�qu'L /o, BUSINESS/AGENCY: <br /> ADDRESS: /✓/ W- k 17V CltylStatelzip <br /> FACn 4-A /. <br /> PHONE(1): 25 3�� 01OO O,3 PHONE(2): SIMILE: <br /> x <br /> TENTATIVE=APPOINTMENT DATE: z a 2006 Time: "7 Qa N'1 <br /> (Please allow 10 business days from datJ of application submittal-"Tentative only-must be confirmed) <br /> Ca CHECK BOX TO EXPEDITE REQUEST-,S1105,FEE(CASH OR CHECK ONLY)-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT �� �/� �A^�� % Z n <br /> Electronic Informat <br /> 4D USE ONLY <br /> Street# <br /> 1. Unit 1 <br /> 2. 320 ❑ Unit <br /> 3. 10 <br /> —.. - - - Unit 3 <br /> 4. <br /> r <br /> 5. - a �- <br /> Lo_s °' <br /> /1'0 <br /> Unit 4 <br /> L3 unit 5 <br /> r n <br /> 8. <br /> 9. Q - <br /> Ll unit 6 <br /> 10. <br /> Specific Date Range of - - -- - - <br /> t <br /> NDERGROUND TANK(US 1/ 'ACIUTYNEHICLE <br /> OTHER CLEANUP SITE(N( <br /> -- <br /> NDERGROUND TANK(M(------- -- - <br /> AZARDOUS WASTE GENE <br /> ARE ATM EN T P LANT <br /> TIERED PERMITTED FACILI -"-IYARD/CHEM TOILETS <br /> TATTOO/BODY PIERCING _ICATION SITES <br /> 0 MEDICAL WASTE FACILITY <br /> WELL AND SEF :LUDING HOLIDAYS, <br /> 1. List up to ten addre, acking the appropriate <br /> box(es). At least on - - dicated above. Address <br /> ranges will not be a( plications received after <br /> 3:00 pm will be proc <br /> 2, The EHD will notify t Tied approximately ten(10) <br /> days after receipt of -- - --evlew. Appointments <br /> should be schadulec <br /> 3. A file that Is actively __ A new application may be <br /> submitted when the,----- <br /> 4. <br /> he,-- -4. Any file not returned In the same condition as released will be reorganized by EHD staff at the expense of the applicant. <br /> Future file reviews by the same applicant may require a$105 deposit prior to review. <br /> EHD USE ONLY <br /> EHD 46-06 8)04108 PUBLIC RECORDS RELEASE APP FORM <br />