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D SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> �P X404 ENVIRONMENTAL HEALTH DEPARTMENT <br /> 5 <br /> 4 -304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> (D9�468-3420 Fax: (209)464-0138 Web: www.co.san joaquin_._muslehd ,. <br /> ENV1Ra�1° �• .� <br /> ERM�T(SC-.RViSE� <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: l c T� "� BUSINESSIAGENCY: ��{ ���'� �G•-�v S��v`� <br /> ADDRESS: <br /> PHONE:. 4 C i -3<-? 7—9G 6----FACSIMILE: `T -20 ._ c� gk� c <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 APPLICANT /3� 107 DATE U <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> usT, , ,ItL,oGs k <br /> 35� sweet � Sa � ct• <br /> My <br /> 0Unit 1 <br /> / a` d � <br /> 3. Stree! ! e <br /> �'1 � t r � � ❑ unit 2 <br /> c G q-17� <br /> 4. SbW <br /> IC cityt Unit 3 <br /> aty <br /> r: street a Unit 4 <br /> S. Street <br /> a <br /> 9. street city ❑ Unit 5 <br /> CRYr <br /> street <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(US-F)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SoUa WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY E3 SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) 13DOG KENNEL E3DAIRY <br /> HAZARDOUS WASTE GENERATOR E3CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILn Y ❑ MOTELIHOTEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> 0 TATTOOIBODY PIERCING 11POOLJSPA ❑ 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 209 454-0138 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 /> fi. Applications received after 3:00 pm will be processed the next business day. ,) <br /> CONFIRMED APPOINTMENT.DATE <br /> -TIME <br /> F <br /> DATE CONFIRMED _ PHONE . : FAX <br /> z It+IITIALS':° <br /> REVIEWED YES NO REVIEW DATE <br /> i46 48-02-006 <br /> 818!2003 ,;I <br />