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10-02-2080 0B'01Ff5 FR TO TO 1925FB63039 P.01 <br /> p,.'i t NECiJ V Ep LAD LLK Nu..l ell <br /> SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> `y I 304 EAST WEBER AVENU E,THIRVI FLOOR <br /> STOCKTON CA 95202 <br /> (209)4683420 <br /> 6BLIC RECORDS RELEASE APPLICATION / 7E <br /> APPLICANT 'SLY V �0� � BUSINESSIAGENCY EDD <br /> ADDRESSS I iii � ^� q 9 RO QOO <br /> PHONE •2.f5 U L aRj FACS)MGE <br /> TENTATIVE,APmiiiMENA.sd' <br /> TDATEy- dn„ � '1Q&lop TIME Ji): n 0-en lrjSt V/CFSrH <br /> i(Piease give 7 to 10 b s cays mm date of appOcaU 'SUMMal) <br /> CHECK BOX TO EXPEDITE REQUEST.$87.00 FEE-REQUEST PROC IN 3 BUSYiF..55 DAYS <br /> SIGNATURE OF APPLICANT DATE <br /> I <br /> ' THIS SIDE EHD STAFF USE ONLY <br /> FILE ADDRESS PROGRAM ELEMENTS SEARCH <br /> 53 E. IC+or ben <br /> IA)C.4 LA <br /> LD <br /> - <br /> - finer <br /> cj b I i clD <br /> n l f i i ENVIRONMENTAL HEALTH DNISION FILES <br /> I <br /> SOLID WASTE FACILITY <br /> FS UNDEROROUNO TANK N�Ci EANUP SITE(LOP) 13 d FOODNG;ABATEMENT )k FACILITY 1131,SOLID WASTE VEHICLE <br /> 0,OTHER CLEANUP SITE(NON-LOP) I ❑ 000 KENNEL DAIRY <br /> '.�-UNDERGROUND TANK(NIONITORINGfREMOVAL) C1 CHICKEN RANCH O PKGTREATMENT PLANT <br /> NAZARDOUs WASTE GENERATOR -FEL MOTELlLt -FEL ❑ PUMPER TRUCKIYARDICHEM TOILETS <br /> TIERED PERMITIND FACILITY I ❑ POTELIHOLISPA •PI.LAND USE APPLICATION SITES <br /> ❑ TATTOp/BODY PEIRCING i7QPUBLIC WATER SYSTEM ❑ OTHER(PLEASE SPECIFY ABOVE) <br /> 'p ; MEDICALWASTE FACILITY <br /> Of files from the fist above by checking <br /> 1. List up to ten addresses 1 the space above. Select the type(S) <br /> the appropriate bakes). At least one file type MUST be selected. F r tor209)464.0138 or mall to the <br /> address indicated iabava. <br /> 2. EHD will notify the�applicAnt if any EHD files exist An appointment for review will be confirmed <br /> approximately fivelbusiness days but no later than ten(10)days after receipt of application.-The files <br /> will be held for a maximus'' 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 returndin the same condition as released will be reorganized by ED th <br /> Hstaff at e expanse <br /> of the applicant Future file reviews by the same applicant may require a$87.00 deposit prior to review. <br /> 5 'TENTATIVE appointment!dates must be confirmed with EHD staff. <br /> 6. Applications receWed after 3:00 pm will be processed the next business day. <br /> I <br /> FDATE <br /> ED APPOINTMENT DATE TIME <br /> FIRMED <br /> PHONE FAX INITIALS <br />