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.ti SAN JOAQUIN-COUNTY <br /> CF11 ��I1 V _ LJ EN , I R t CENTAL HEALTH DEPARTM _e <br /> 304 E V+ giber Ave 3 Floor Stockton, C 95205 <br /> ­NOV 21 21�Q9) 465-3420:Fax: (209) 464-0138 Web: www.co.san-joaquin.ca.us/chd <br /> ENWONMENT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: T <br /> BUSINESSIAGENCY: S <br /> TQAJ <br /> ADDRESS: " <br /> PHONE L d S CrP 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,P.ROCESSED IN 3 BUSINESS DAYS <br /> DATE <br /> SIGNATURE OF APPLICANT ��r'��� 1 1 D3 <br /> —. <br /> � - department Use Only <br /> " UNIT <br /> 7 FILE ADDRESS - +1 <br /> t. Street r✓ ❑ Unit 1 <br /> C�� �2 <br /> 2. Street City <br /> 1, <br /> 3. Street Lf C J csCil ❑ Unit 2 <br /> 4. Street <br /> 5. Street Gt Unit <br /> 6. Street Cil <br /> r. Street City Unit 4 <br /> 9. Street Cit - <br /> 9. Street Cil <br /> 10. Street DI <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES = <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) El HOUSING ABATEMENT 0 SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) 0 FOOD FACILITY 0 SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MON ITORINGIREMOVAL) 0 DOG KENNEL 0 DAIRY <br /> HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH ❑ PKG TREATMENT PLANT, <br /> ❑ TIERED PERMITTED FACILITY 0 MOTELIHOTEL 0 PUMPER TRUCK/YARDICHEM TOILETS <br /> C3 TATTOOIBODY PIERCING 0 POOLISPA 0 LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY 0 OTHER(PLEASE SPECIFY) <br /> i. 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 fifes 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 /> *- Any file not returned in the same condition as released will be reorgy a, , ' he expense <br /> of the applicant. Future file reviews by the same applicant may req 3. por to review. <br /> �- *TENTATIVE appointment dates must be confirmed with EHD staff. <br /> ti. 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 /> E110 48-02-006 <br /> S <br />