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SAN JOAQUIN COUNTY EHD LOG NUMBER <br /> ((�((�� &''I<tONMEN'l AL HEALTH DEPAR'T'MENT <br /> W L C11'� V [E D 304 E Weber Ave 3'd Floor Stockton, CA 95205 <br /> (209)468-3420]Flax; (209)464-0138 Web: www.co.sara joagtlan.ca.us/ehd <br /> MAR — 9 2005 <br /> p p� Z5 7 <br /> PUBLIC <br /> �jRECORDS RELEASE APPLICATION <br /> BUSINESSIAGENC � �.T.— .-.._ <br /> ADDRESS: �� � � •S L�-F <br /> PHONE: FACSIilA1L E, 3 <br /> l TENTATIVE*APPOINTMENT DATE; 31. 1 f v Time: <br /> (Please allow 10 business days from date of application submittal) <br /> CHECK BOX TO EXPEDITE REQUEST.$9 .00 FEE– EQUEST PROCESS91)IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT BATE c� b <br /> Department Use Only <br /> FILE ADDRESSuNtT <br /> sz+,Belcn <br /> z. 91rsc[ a[ ❑ Unit 1 <br /> 3. Slrcry �' <br /> ❑ Iinit2 <br /> - 5. SVecl g • �t� f �1 •��o�� � '� <br /> t <br /> G. situs[ ;Unit.3. <br />` <br /> [ <br /> 7. Stns! C7 <br /> rlrt`4 <br /> 9. 5lrrq! <br /> to, Strcel Gr �� :unit 5 <br /> c1tv <br /> ENVIRONMENTAL FIEALTH DEPARTMENT E <br /> NT FIDES <br /> �( UNDERGROUND TANK(UST)CLEANUP SITE(LOP) HO <br /> OTHER CLEANUP SITE ON-LOp 0© 1151NG ABATEMENT 0':SOLED WASTE FACILITY <br /> FOOD FACILITY ID SOLID WASTE VEHICLE <br /> IN' UNDERGROUND TANK(MONITORINGIREMOvAL) Q DOG KENNEL <br /> HAZARDOUS WASTE GENERATOR. O CHICKEN RANCH O DAIRY <br /> ?. TIERED PERIU MI=D FACILITYTATTOpI80DY PIERCING E PKQ TREATMENT PLANT <br /> Cl b MOTELRipTE1 {J iPumPER TRUCKIYARD/CHam TOILETS <br /> CI POOLISPA 13 : <br /> © MEa1CAL WASTE FACILITY OTHER(PLEASE SPECIFY) LAND USE APPLICATION SITES <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 209 464-0738 or mail to the <br /> address indicatd 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 tett(10) days after receipt of application. The files <br /> will be held for a rnaximUM 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 1*HD staff at the expense <br /> of the applicant. Future file reviews by the same applicant may require a$83.00 deposit prior to review. <br /> 6. *TENTATIVE appointment bates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the Next business day. <br /> EREVIEWED <br /> APPOINTMENT DATE TIME <br /> ED PHONE FAX INITIALS <br /> YES NO REVIEW DATE <br /> aHo�a•oz.aos <br /> e+sr�aas <br /> k <br /> f <br />