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EHD LOG NUMBER <br /> OATS RECEIVE-_0 SAN JOA.QUIN COUNTY <br /> RD CCD V LSD ENYYRONM[ENTAJ�a�IFA1,T11 DEPARTMFNT <br /> 304 E Weber Ave 3 Floor Stockton, CA 95205 <br /> n, 200209)468-3420 Fax: (209) 464-0138 Web: wwtiv.co.san joaquin.ca.us/eh.d <br /> ENVIRONMENT HEALTH PUBLIC RECORDS RELEASE, APPLICATION <br /> APPLICANT:(� BUSINESSIAGENCY: �GW `S1Q 'l ✓71 � <br /> ADDRESS: qa�( <br /> PHONE: 7-.r5-70 FACSIMILE: a ala ,- 1122 <br /> TENTATIVE*APPOINTMENT DATE: Time: <br /> (Please allow 10 business days from date of appilcation submittal) <br /> CHECK BOX TO EXPEDITE REQUEST-$93.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS / <br /> SIGNATURE OF APPLICANT w � �' DATE <br /> Department Use OniV <br /> FiLE ADDRESS. UNiT <br /> s1. sirsel n �1 Cit ❑ Unit 1 <br /> U—Qto/ ,p 2. Slteel <br /> eff 0 0.W' `Cis reet ❑ Unit 2 <br /> off 4. :Irccl Gly - —-- <br /> >irgrl Gt Unite <br /> na- 5, <br /> - GI <br /> G. street <br /> �. slreel C11 X Unit 4 <br /> e, Sim` al <br /> 9. Sheet Cil ❑ Unit 5 <br /> t0. Slr*>Ft G <br /> ENViRONMENTAL HEALTH DEPARTMENT FILES <br /> R UNDERGROUND TANK(UST)CLEANUP SITE(LOP) Q HOUSING ABATEMENT M SOLID WASTE FACILITY <br /> M(OTHER CLEANUP SiTE(NON-LOP) ❑ FOOD FACILITY d SOLiD WASTE VEHICLE <br /> M(UNDERGROUND TANK(MONiTORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> W HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH M PKG TREATMENT PLANT <br /> Lg TiERED PERMITTED FACILITY 0 MOTEUHOTEL 0 PUMPERTRUCKIYARD/CHEM TOILETS <br /> ❑ TATTOO/BODY PIERCING L3POOUSPA O LAND USE APPLICATION SiTES <br /> CO 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 now <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, f=uture 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 AFPOiNTME:NT DATE TIME <br /> DATE CONFiRM50 PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> fiHb 40.02-0oe <br /> Slarz000 ' <br />