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DATE RECEIVED EHD LOG NUMBER <br /> �(� SAN JOAQUIN COUNTY <br /> o sc �J SID ENVIRONMENTAL HEALTH DEPARTMENT <br /> r <br /> ��(p��(}} 304 E Weber Ave 3`d Floor Stockton,CA 95205 6 ? <br /> NQS - x•(209)468-3420 Fax: (209)464-0138 Web:www.co.san-joaquin.causlehd <br /> HAg0A 21 <br /> SMV p,() WE GV S PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: 2U e LL—F(-j 2 BUSINESSIAGENCY: <br /> ADDRESS: S J Pita P � e L.A 2,� ��,: �3, (2 o e u t�� . C �.s 6 7� <br /> PHONE: h - �17- / 77E FACSIMILE: � G - 77- /7 70 <br /> TENTATIVE*APPOINTME TITE: Time: <br /> (Please al 10 business days from date of application submittal) <br /> 13 CHECK BOX TO EXPEDITE REQUEST-$ 0 EQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT DATE 1 U <br /> Department Use Only <br /> ILE ADDRESS UNIT <br /> 10 Street .20sq /U�1� �2 ❑ • Unit 1 t� <br /> Street Ct( A0 (/F— c <br /> 3. Street aty �(A <br /> ❑ Unit 2 <br /> 4. Street city <br /> \� <br /> S. street G Unit 3 <br /> 6. Street city <br /> 7. Street �rU7nit <br /> e. sweet City <br /> 9. Street a Unit 5 <br /> 10. Street aty <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> 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(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCKIYARD/CHEM TOILETS <br /> ❑ TATTOO/BODY 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. Afile 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 EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED AF'ROINTMENT.DATE TIME v r. <br /> DATE CONFIRMED = PHONE FAX' INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 48-02-006 <br /> 8/8!2003 <br />