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DATE RECEIVED EHD LOG NUMBtK <br /> SAN JOAQUIN COUNTY <br /> FED-) �U L., .'IRONMENTAL HEALTH DEP4_NIENT <br /> 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> JAN 3 0 ) 468-3420 Fax: (209) 464-0138 Web: www.co.san-joaqu1n.ca.us/ehd <br /> ENVIROvi',ItHT HEALTH PUBLIC RECORDS RELEASE APPLICATION <br /> n r \/ <br /> APPLICANT: 1`L V l /Ica"?TSN ESS/AGENCY: <br /> ADDRESS: C) r) <br /> PHONE:-� -- n�_-�I FACSIMILE: <br /> TENTATIVE`APPOINTMENT DATE: /G?E 4f-,ter)r"/"K-_CT_Ibie: <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 DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> ,. Street a �S:F ❑ Unit 1 <br /> 2. Street c <br /> ity <br /> 3. Street Ci - <br /> ❑ Unit 2 � <br /> 4. Street Oty <br /> 6. Street aty Unit 3 <br /> 6. Street o <br /> ty <br /> 7. Street city Unit 4 <br /> 8, Street cjty <br /> 9. Street c' ❑ Unit 5 <br /> 10. Street C'ty <br /> J ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 0 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(MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DA1RY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOOBODY 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 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 END 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 /> EHO 48-02-006 <br /> 8!872003 <br />