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10/28/2004 10:24 FAX 209 948 SAN JOAQW COUNTY <br /> pr;�"REG£IVED <br /> <� <br /> ENVIRONMENTAL HEALTH DEPARTMENT O <br /> 304 E W0beT'Ave 3'd Floor Stockton,CA,95205 ehd 2 <br /> (209) 468-3420 Fax: (209)464-0138 Web:www.co.salljoaqu m <br /> PUBLIC RECORDS RELEASE APPLICATI ON <br /> 7 T4r�5lf, BUSWESSlAGENCY: <br /> APPIJCANT: zJA. o <br /> ADDRESS: � <br /> FACSIMILE; <br /> �/ <br /> PHONE:,d�—�--- !z;•�— <br /> TENTATUF APPOINTMENT DATE: <br /> (pteaso allow 10 business days from data of application submittal) <br /> EAFEOfTE R <br /> CHECK BOX TO EQUEST-$S3.00 FEE—REQUEST PROCESSED IN 3 BUSINE5S DAYSDATE <br /> SIGNATURE OF ppPL1CANT Devartmene tlsa Only <br /> UNIT <br /> FILE ADDRESS ZA <br /> Unit 1 <br /> � G <br /> 3t rtN k I f� r"- Unf 2', �\OJ <br /> z. SrcN G <br /> q N.W.lbcrr�- <br /> s�d yo ro .s1Aa �} lr' unit \� <br /> q 12b G <br /> UnR 4 <br /> 0 <br /> r. suedcft tftR � Unit 5 <br /> 1 t � � .; <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ HOUSING ABATEMENT ID SOLID WASTE FACICLE <br /> CLEANUP SITE(LOP) O FOOD FAAILITY ❑ 8000 WASTE VEHICLE <br /> ,J24 UNDERGROUND TANK pN-LOP] 0 DAIRY ' <br /> 13 OTHER CLEANUP Sat(N d DOG KENNEL J j PKG TREATMENT PLANT <br /> HEM TOILETS <br /> IIA UNDERGROUND TANK(MONFrORINGlREMOYAI-) O CHICKEN RANCH ❑ pUMPERTRUCKIYARDIC <br /> !3 HAZARDOUS WASTE GENERATOR ❑ MOTEUHOTFL >a- LAND USE APPLICATION Sr7Es <br /> ❑ 'n£RED pERmnTED FACILITY ❑ pO0U3PA ESP£CIFY) <br /> El TATTOOrBO0Y PIERCING ❑ OTHER(PLEAS checking <br /> ❑ MEDICAL WASTE FACILITY of files from the list aboYe W <br /> 1 List up to ten addresses in the space above. Select tho"(s) <br /> the appropriate box(es)" At least one file type MUST be selected. Fax to 209 464-0138 or mail to the <br /> address cated above. for review will be confirmed <br /> 2 EHD will notify the applicant if any EHD files exist to appointment10 <br /> Appointments should be scheduled <br /> approximately five business days but no tater than ten{10)days after receipt of application. The files <br /> will be held for a maximum of five business days for reviow. ApP <br /> accordingly. eing Worked on by not be immediately available for review. Anew <br /> 3 A file that is adivbeel subm'tted when the file Ds available. <br /> application may deposit prior to review <br /> 4• Any file not returned in the same condition as feleas me i cant may require a$93.00Hd ptaft the expe� <br /> of the applicant- Future ointmentte reviewsdate$ mut behconflrmedwith END Staff: <br /> 5• <br /> TENTATIVE app <br /> g Applications To, <br /> after 3:00 pm will be processed the next business ay. <br /> .i v..- r-.+ <br /> ;TIME .x .. .:.:: .' "... .. . ... :. <br /> ... ., FAX'• ., ::�: <br /> �Y <br /> ND R6VIEVVDATE; ;.. ..:.. - <br /> REVIEV`!ED <br /> ' EH018-02AV6 <br /> YY1�� <br />