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FROM : Ground Zero Analysis PHONE NO. : 209 838 9883 Nov. 02 2005 11:41AM P1 <br /> DATE RECEIVED EHD LOG NUMBER <br /> ,SAN JOAQUIN COUNTY <br /> LI ENVIRONMENTAL HEALTH DEPARTMENT <br /> 22@5 304 E Weber Ave 3Td door Stockton, CA 95205 <br /> (209)468-3420 Fax: (209)464-0138 Web: www.co.san-joaquin.ca.us/ehd <br /> PUBLIC RECORDS RELEASE APPLYCATION <br /> FF �S <br /> APPLICANT= BUSINESS/AGENC <br /> ADDRESS: ` C � <br /> � n- (f�4 C �1�rr <br /> PHONE f� J Rag ` /c�rTFAMMIL <br /> TENTATIVE*APPOINTMENT DATE: / Time: �� o D Q .m . <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$9 00 F — EQUEST PROCESSED IN S BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> Department se Only <br /> FILE ADDRESS UNIT <br /> '' ` Ll r4 TE ° O G n ❑ Unit 1 <br /> 7. save+ city1G1 <br /> .�Z/ <br /> 4 sued ❑ Unit 2 �j <br /> \10 <br /> s. saeo1Unit <br /> 6, baser C <br /> 7. Strvot <br /> 3 StradCRY <br /> 9 shad CRY ❑ Unit 5 <br /> io. saeec Uy <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON4-OP) C] FOOD PACILITY 0 SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) CI DOG KENNEL d DAIRY <br /> HAZARDOUS WASTE GCNERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PEwirTED FACILITY ❑ MOTELMOTEL Q PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING ❑ POOUSPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE KACILITY 0 OTHER(PLEASE SPECIFY) <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 appropriate box(es). At least one file type MUST be selected. Fax to(2091464-0138 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 hold 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 game condition as released wail be reorganized by EHD staff at the expense <br /> of the applicant. Future file reviews by the some 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 APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> LHp�scaaoe <br /> moo <br />