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EHD LOG NUMBER <br /> DATE RECEIVED Iecs <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 E Weber Ave 3 Floor Stockton,CA 95205 <br /> 468-3420 Fax: (209)464-0138 Web:rvww.co.san-joaquin.ca.us/ehd <br /> NZ \00 A <br /> ENVIR�NM qNV S PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: eve BUSINESSIAGENCY: <br /> r {� S -F6 7e <br /> ADDRESS: S JI�l/1A5/k �R 2�'� s� <br /> PHONE: FACSIMILE: <br /> TENTATIVE*APPOINTME T TE: <br /> Time: <br /> (Please al 1'0 business days from date of application submittal) <br /> 13 CHECK BOX TO EXPEDITE REQUEST-$ 0 EQUEST PROCESSED IN 3 BUSINESS DAYS <br /> DATE l/Lfo-x <br /> SIGNATURE OF APPLICANT Department Use Only <br /> UNIT <br /> ILE ADDRESS <br /> 05 ,qv �2 �� �, ❑: Unit 1 <br /> 2. street Z2 ❑ Unit 2 0 <br /> G <br /> 3. Street \( <br /> 4 ` Unit 3 N <br /> s. street <br /> Ci <br /> 6. street Unit 4 <br /> L7. Street <br /> StreetUnit 5 <br /> Street <br /> Street <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 13 HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> OTHER CLEANUP SITE(NON-LOP) ❑ Dom,KENNEL ❑ DAIRY <br /> UNDERGROUND TANK(MONITORINGlREMOVAL) ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ MOTELfHOTEL ❑ PUMPER TRUCKtYARD/CHEM TOILETS <br /> ❑ TIERED PERMITTED FACILITY ❑ POOLISPA ❑ LAND USE APPLICATION SITES <br /> ❑ TATTOOIBODY PIERCING ❑ OTHER(PLEASE SPECIFY) <br /> ❑ MEDICAL WASTE FACILITY <br /> pe(s)of files from the list above by checking <br /> 1. List up to ten addresses in the space above. Select the ty <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 /> rked on by EHD staff may not be immediately available for review. Anew <br /> 3, A file that is actively being wo <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 EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE <br /> TIME <br /> -DATE CONFIRMED <br /> PHONE FAX. INITIALS <br /> ~ REVIEWED YES NO REVIEW DATE. <br /> EMD 48-02-006 - <br /> RLBr'= <br />