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DATE RECEIVED EHD LOG NUM_nER <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3'd Floor Stockton, CA 95205 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: wNv­w.co.san_joaqu1n.ca.us/ehd q07 <br /> n PUBLIC yRE, CORDS RELEASE APPLICAATION <br /> APPLICANT:y(OJ��;/� /C� �Io� �C BUSINESS/AGENCY: <br /> ADDRESS: <br /> PHONE: 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 PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT � �-�� �r`� �'-yz�Cf� DATE �C.r r� �. <br /> Department Use Only <br /> FILE`ADDRESS C UNIT <br /> 1. Street X ' c J� ❑ <br /> 2. Street Unit 'I <br /> r <br /> � � ( Y, Ci <br /> 3. Street Cit ❑ Unit 2 <br /> 4. Street city <br /> 5. Street C'ty ❑ Unit 3 <br /> 6. Street City <br /> . Street city �Unit4 <br /> 8 <br /> e. Street Ci <br /> 9. Street city ❑ Unit 5 <br /> 10. Street C <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES ,I <br /> d—UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> O OTHER CLEANUP SITE(NON-LOP) I] FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> UNDERGROUND TANK(MONITORING/REMOVAL) ❑ DOG KENNEL O DAIRY <br /> 11 HAZARDOUS WASTE GENERATOR 173 CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> TIERED PERMITTED FACILITY ❑ ,MOTEL/HOTEL M PUMPER TRUCK/YARD/CHEM TOILETS <br /> TATTOO/BODY PIERCING O POOL/SPA ❑ LAND USE APPLICATION SITES <br /> O 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 EHD staff at the expense <br /> of the applicant. Future file reviews by the same applicant may require a$93.00 deposit prior to rev.lew. <br /> 5. *TENTATIVE appointment dates must be confirmed with EHD staff. yJ <br /> 6. Applications received after 3:00 pm will be processed the nex usine s day <br /> 1� <br /> CONFIRMED APPOINTMENT DATE / TIME Udo <br /> DATE CONFIRMED PHONE . _F FAX INITIALS i—T Ari) <br /> 1A � <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 48-02-006 <br /> 8/8/2003 <br />