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\�-) - J JAN J OAQUIN COUNTYri _ ENVT NMENTAL <br /> HEALTH DEPARTM' <br /> APR 1 5 2004 304 r- Weber Ave 3rd Floor Stockton, CA 95205 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: wtivw.co.san joaquin.ca.us/ehd -75 <br /> 17 <br /> IrES p LIC RECORDS RELEASE APPLICATION <br /> APPLICANT: K J9L .s. SE/ftlo�✓ BUSINESS/AGENCY: <br /> ADDRESS: :zb ?/ �R� L19 !v C n-9, q $377 <br /> PHONE: 'aO Q' HS-6— I L(6 D FACSIMILE: -13c - 75-Sa <br /> TENTATIVE'APPOINTMENT DATE: <br /> Time: 4,P P <br /> (Please allow 10 business days from date of application submittao <br /> CHECK BOX TO EXPEDITE RE EST-$93.00 FEE—REQUEST PROCESSED IN 3 BUSINESS DAYS <br /> SIGNATURE OF APPLICANT -� DATE 1- 5--04f <br /> Department Use Only <br /> FILE ADDRESS UNIT <br /> 1. street 18S t-4- 4 V 7-1 CL 0 F, qt, S TC ICfc o <br /> T N gS�oy <br /> 2. Stmt U25T v v v Unit 1 <br /> 3. S� <br /> C+ <br /> t. street ❑ Unit 2 <br /> S. stmt <br /> Ci Cidlrl <br /> s. sleet Unit 3 <br /> 7. Street <br /> e. street <br /> Unit 4 <br /> 9. Street City <br /> L.10. Stmt City <br /> ❑ Unit 5 <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ® UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABATEMENT ❑ SOLID WASTE FACILITY <br /> ® OTHER CLEANUP SITE(NON-LOP) N FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> 9 UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> W HAZARDOUS WASTE GENERATOR ❑ CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> 0 TIERED PERMITTED FACILITY ❑ MIOTELIFiOTEL ❑ PUMPER TRUCK/YARDICHEM TOILETS <br /> ❑ TATTOOA30DY PIERCING ❑ POOLtSPA ❑ 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(209)464-0138 or mail to the <br /> address indicated above <br /> 2. END 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 END 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$93.00 deposit prior to review. <br /> 5. 'TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3:00 pm will be processed the next business day. <br /> CONFIRMED APPOINTMENT DATE TIME <br /> DATE CONFIRMED <br /> PHONE FAX 1NIT.IAL$ T. <br /> REVIEWED YES NO REVIEW DATE <br /> EHD 48-02-006 <br /> 9=2003 - <br /> I <br />