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Hug Lb U4 U9: 49a P'iF s. 408-559-1224 P. 1 <br /> N%w <br /> DATE RECEIVED EHD LOG NUMBER <br /> J ll �� Vn D SAN JOAQUIN COUNTY <br /> I,� ll C C ���/IE D ENVIRONMENTAL MALTH DEPARTMENT <br /> 304 E Weber Ave 3ra Floor Stockton,CA 9205 <br /> AUG 2(&900g-3420 Fax: (209)464-0138 Web: vww.co.san-joaquin.ca.us/ehd <br /> ENVIRONMENT HEALfPLIC RECORDS RELEASE APPLICATION <br /> i. <br /> APPLICANT: /� Se BUSINESSIAGENrC1Y: <br /> ADDRESS: 1�SD . (I co,-, AV-e It�SC�A�J9t SrUI"�O <br /> PHONE: �, t0 1�G—Q, _+ t0✓l 1M <br /> nll Se YVj�p JC <br /> FACSIMILE: 7 � I-)-a 4 <br /> .�a <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQURITT PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE w <br /> Department Use Only <br /> / FILE ADDRESS / ,.f`" UNIT <br /> t. Svaet �y$Z? t-- 1�/ �7(r6 Cityu• " ✓q O ❑ Unit 1 <br /> 2. Street D ( 0. ZlO cal, V112 <br /> 3. street c. ❑ Unit 2 <br /> 4. Street oty <br /> s Street city nit 3 <br /> 6 Street oty <br /> 7. street Oty Unit 4 <br /> 6. Street city <br /> 9 scree, city ❑ Unit 5 <br /> to. street <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> OTHER CLEANUP SITE(NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY U fJ U gyp. <br /> j$ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY E3 MOTELIHOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOL(SPA ❑ 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 END 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 /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHp 46-02-066 <br /> uenoos <br />