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09-24-2W1 03=13PI'I FRL lU ;tb3.-tEut�1 N.e). <br /> SAID! JPAQUIN COUNTYPUBLIC HEALTH SFRVICES �}— <br /> EWRONMENTAL HEALTH DIVISION 1`~ <br /> �. !304 CAST WESER AVENUE,THIRD FLOOR <br /> i STOCKTON CA 95202 <br /> (209)465- 420 <br /> RECORDS RELEASE APPLICATION <br /> APPLtCAAtT ��f <br /> ADDRESS <br /> ' / <br /> PHONE Ellb-t2" 1�`t FACSIMILE�� <br /> TEIS•T•A.TIVE'APPOINTmEN7 DRtr TIML <br /> (PIC?i0 Irvc 1 to 1V 04t61c331 days trOrd d2W of app=i=atlon a`�iin`%;R011 <br /> L] CHECK BOX TQ EXFEDBE R 5 -5B7,00 FEE-REQUEST PROCESSEDIN 7 BUSINESS DAYS <br /> 5I43NATURE OF APPLICANT DATE <br /> FILL:ADOR£ss THIS 522E END STAFF USE ONLY <br /> PROGRAM ELCMENl'5 SEARCH <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> {�� <br /> UNi2hKGRDVNI3TANK(U5T)cLEArive amt(L 4P) U HOUSING ABATEMENT W SOLID WA5TE FACILITY <br /> POTHER CL4ANUP SITE(MON-LOP) 0 FOOD FACILITY 0 SOLID WASTE VEHICL.E <br /> UKPEDFRMIT <br /> 0Uk0 YA11K(N D`R'yOR(NGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> HAZAUS WA57t t;El ERATOR 0 CHICKEN RANCH D PKGTRFATMeNTPLANT <br /> Alii TlEXt TED FAG(LITY ❑ MOTEL/HOTEL 0 FIJIVlYFR TRtICN71fARDlGHE?4TOtLLTS <br /> ❑ TATTOOMODY PEIRCING 0 POOL/SPA 0 tANO VSE APPLICATION 51TL5 <br /> © mEiNCAL WASTE FACILIYY 0 PUBLIC WATER SYSTEM Q OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to telt addresses ill the space above. Sulect the type(s)of files from the list above by checking <br /> the appropriate box(es).:At icast one We type MUST be selected. Fax to(2Q )1_4G4-D•13t3 or n+aii to the <br /> address indicated above. <br /> 2. CHID will notify ttia applicant if any FMO files exist_ An appointment for revieW will.Do Confirmed <br /> approximately five busiticss days but no later than ten(10)days after ft:ctipt of application_ The files <br /> will be held for a maximum Of five business days for review. Appointments should be Scheduled <br /> actordingly. <br /> 3. A file that is actively beiiig worked on by EHD staff may not be immediately availabtc for review. A new <br /> application may be submitted when the file is available. <br /> 4. Any tUc not returned in the sank COAditidn as released will be reorganized by END stall At the expense <br /> o1 the applicant. Future file reviews by the same applicant may require a$67.00 deposit prior to review. <br /> S. ITENTATIVE appointment dates must be confirmed with EHD staff. <br /> G. iApplicadons received after 3:00 pm will be processed the next business day. <br /> CoI f IRMED APPOINTMENT-Dj TE __ TIME <br /> i <br /> DATE CONFIRMED _ PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> • TOTfaL P.01 <br />