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EHD LOG NUMBER <br /> DATE RECEIVED 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: wrvw.co.sanjoaquin.ca.us/ehd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: L Cj Sl t e� BUSINESS/AGENCY: A <br /> ADDRESS: 3 ` <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 U DATE <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> t. Street 2 r23 / 2(�z3 E• Mi Avg city EKalvK ❑ Unit 1 <br /> 2. Street Ci <br /> ty <br /> 3. Street c' ❑ Unit 2 <br /> 4. Streel C' <br /> tV <br /> 5. street Ci ❑ Unit 3 <br /> city <br /> 6. Street <br /> 7. Street Ci � Unit 4 <br /> Ci <br /> 8. Street <br /> 9. Street ci Unit 5 <br /> ❑ <br /> city <br /> 10. Street <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(MONITORING/REMOVAL) ❑ DOG KENNEL Cl DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH Cl PKG TREATMENT PLANT <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTELIHOTEL ❑ PUMPER TRUCK/YARD/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 1,209) 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 EHD staff. <br /> 6. Applications received after 3:00 pm ill be processed the next business day. <br /> CONFIRMED APPOINTME DATE TIME <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> REVIEWED YOE NO REVIEW DATE <br /> EHD 48-02-006 <br /> 8/8/2003 <br />