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SAN JC iJ N 'COI. N I YE'lJi3Lir1 HEALTH SE, "ES V. <br /> -AVIRONMENTAL HEALTH DIVISION { <br /> 304 FAST WEBER AVENUE.THIRD FLOO12 <br /> STOCKfON CA 852D2 <br /> (20.9) 458-3420 <br /> PPBLIC RECORDS RELEASE APPLICATION <br /> APPLIC.Aff (fir} 8I1SINESStAGENCY <br /> ADDRESS- 0 0 <br /> PHONE i — oC FAC-51MLE��[�—Otlf'"�7.iV <br /> "1 I I:3o q �` <br /> TENTATrVE`APPOINTMENT DATErtn2{iVG D.z/DIJ01 —TV >'A Y- „kevj& 4' 067-f a ar.,MW0 <br /> (Reese give 7 to 10 business days Cram date of applieation submittal} k s��7�T,fd �°�y <br /> liY1 QLLJ �GK.r�IC 1 <br /> CHECK BOX TO EXPEDITE REQUEST-SL7.06 FEE—REQUEST PROCESSED IN 3 13USINESS DAYS <br /> SIGNATURE OF ADPL ICAN /jf�� <br /> �ATE <br /> FILE ADDRESSO <br /> THIS SIDF END STAFF USE Ly. <br /> FROGRAL1 ELEtaCHTS SEARCH 1 <br /> WF A& o cf <br /> IFF 5y 9 ��- <br /> ✓ a'L E. <br /> n r-NML <br /> ENVIRONMENTAL HEALTH DIVISIO FILES ��D <br /> UNDERGROUND <br /> TANK(UST)CLEANUP SUE(LOP) 0 HOUSING A9ATEMENT O SQLID ASTE FAcILr 2 7 <br /> d OTHER CLEANUP SITE(NON•LpPy' ❑ FOOD FACUTY ❑ SOLID I�UASTE VEHICLE == <br /> VeUNDERCiIZOUNDTANK(L1ONITOMM&REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> O HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> 0 TIERED PERMn-ED FACILITY 10 14MEUKOTEL 0 PUMPER TRWCKlYAR=HEM T011-ETS <br /> 0 TATTOOJBODY PEIRCJNG 0 POOLr$PA " - Q LAND U$EAPP•LCCATIOM SITES <br /> In MEDICAL-WASTE FACILMY ❑ PUBLIC WATER SYSTEM 11 OTHER(PLEASE SPECIFY ABOVE) <br /> 1. List up to ten addresses in the space above. Select the types)of files from the list above by checking <br /> the approprizde bwx es). At least one file type MUST be sel®ctted. Fax to (209) 464-0138 or mail to the <br /> gsidress inidicated bov,e. <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 tent (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 CHID 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 wHI be reorganized by EHD staff at the expense <br /> of the applicant. Feature file reviews by the same applicant may require a$8100 deposit prior to review. <br /> S. 'TENTATIVE appo;ntment dates must be conFinned with EHD stiff, <br /> 6. Applications received after 3;00 pm will be processed the next business day. <br /> I <br /> CONFIRMED APPOIN rAF_NT DATE TInqE <br /> DATE CONFIRMED PHONE FAX INITIALS <br /> D<=1f(�1V�n YCc w�r� <br /> 0C101MAr r4A r= T <br />