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SAN j(14QUiN LOWv4 YPUdLl,1r.'1 <br /> NVIRONMIENTAL HEALTH DIVISIC <br /> 304 EAST WEBER AVENUE, THIRD FLOCK <br /> STOCKTON CA 95202 <br /> 3 5-5 <br /> (209)468-3420 <br /> q"UBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT 8USIWSSIAGENCY <br /> kl"j �g'e -1 <br /> ADDRESS L100 S— A) &)a EI-0 C CA 9�5_--� <br /> /r Spm <br /> PHONE FACSIMILE <br /> TENTATIVE*APPOINTMENT DATETIME 0,LC"_1'Wj <br /> (Please give 7 to 10 busines4 drys from dais of application submittai) <br /> f-HECK BOX TO EXPEDITE REQUEST- 00 FEE—REQUEST PROCESSED IN 3EU "v zS14ESSBAem YM <br /> SIGNATURE OF APPLICANT C 0�L_ X. DATE <br /> )011 <br /> FILE ADDRESS <br /> IL4 <br /> -772,Q DE'S <br /> F <br /> 12- <br /> soft. <br /> 2nol <br /> ENVIRCINMEN.1114 , <br /> ................ <br /> UNDERGROUND TANK(USTI CLEANUP SITE(LOP) C, H'( <br /> OTHER CLEANUP SITE(NON-LOP) 71 F( <br /> UNDERGROUND TANK(MONITORING/REMOVAL) 0 Dt <br /> HAZARDOUS WASTE GENERATOR M CI <br /> TIERED PERMITTED FACILITY 0 11A <br /> TATTO(UBODY PEIRCING M pl ':r; Y—ev i ew 2 <br /> 0 MEDICAL WASTE FACILrTy <br /> 1, List up to tan addresses In the apace ab <br /> the appropriate box(es). At lea3t one fila <br /> Address indicated above. <br /> 2. EHD will notify the applicant if any EIJO ': <br /> approximately five business days but <br /> will be hold for a maximum of five busing <br /> accordingly. <br /> 3. A rile that is actively being worked on by <br /> appHeation may be submitted when the ., <br /> 4. <br /> Any file not returned In the same canditi <br /> of the applicant. Future file reviews by 104 <br /> N <br /> *TE <br /> TATIVEappointment dates must b(.,;, <br /> 6. Applications received after 3:00 pm will ...... <br /> CONFIRMED APPOINTMENT DATE <br /> DATE CONFIRMED <br /> REVIEWED YES NO <br /> EN Do 14 <br />