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tHU LVU NUMt5CM <br /> DATE REC(EIIV�ED il��� S�JOAQUIN COUNTY <br /> ��� u `-'(EE) ENVIk%w IMENTAL HEALTH DEPARTML..'T <br /> n n�4 304 E Weber Ave 3`d Floor Stockton,CA 95205 <br /> EB(2A)246g-3420 Fax: (209)464-0138 Web:www.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALTH <br /> PERMIT/SERVICESPUBLIC RECORDS RELEASE <br /> /APPLICATION �J <br /> APPLICANT: XII ( BUSINESSIAGENCY: ✓�L(/t/ &71 nn <br /> ADDRESS: 10 :25 t <br /> PHONE: Wk <br /> FACSIMILE: <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE-REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT2-/- _ DATE <br /> Departmen Use Only <br /> FILE ADDRESS UNIT <br /> 1. street (0 3 �Fr4 y- P`3507 -T [] Unit 1 n <br /> 2. Stmt 16 t1 O G city — ALU 4 <br /> �N� <br /> 3. stmt `3C3 ' C 011 Unit' <br /> 4. stmt 3 C en l <br /> S. stmt 3 Q d a 02 Unit 3 <br /> Street <br /> 6. 8 r-1 t �!�L'L�.r 0 <br /> 7. Street 2-2 2- -7 Ci � U <br /> S. Street — <br /> 9. Street -j-<r 0 ci Unit 5 <br /> 10. Street T ;k_:!�5- oo <br /> a <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ENDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT SOLID WASTE FACILITY <br /> ER CLEANUPSITE(NON-LOP) ❑ FOOD FACILITY SOLID WASTE VEHICLE <br /> ERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL DAIRY <br /> ARDOUS <br /> WASTE GENERATOR ❑ CHICKEN RANCH rWPKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL —E3"-PUMPER TRUCKIYARDICHEM TOILETS <br /> O TATTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE FACILITY ❑ 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(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 file not returned 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$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 /> ZONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED. :.PHONE FAX" `INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHO 43-02-006 - <br /> &W2003 <br />