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b / ( Zl / 'G7✓J4 16 : Od Ztl7-bly- 2ZYb MUDESIU AIG <br /> SAN JOAQUIN COUNTYPUBLIC HEALTH SERVICES <br /> a �� I1ED ENVIRONMENTAL HEALTH DIVISION <br /> � t <br /> f (� ;, _ 304 EAST WEBER AVENUE, THIRD FLOOR <br /> - STOCKTON CA 05202 ' <br /> JUL 21 Z�04rr ) 468-3420 <br /> Pe� U/B1lLIIC RECORDS �RELEASE APPLICATION <br /> APPLICgt4fi ` I ( E �.IW /"Y` `�-"I BUSINCSSIAGCNCY / `r(� <br /> ADDRESS }h/�v <br /> II <br /> t�01un ' �U . k R /o <br /> PHONE Z�`i p , l - Z,x-" 1 FAC (MILE _ �.� �r r�-�! •^ '(,Z 'l ) '- <br /> TENTATIVE" APPOINTMENT DATE D'i TIME II�a <br /> (Plca:c OivC 7 to � 0 tlu,lnoss days (rain dolt of applia7lion sUbmillyp <br /> CHECK BOX TO,EXPEDITE REQUCST • $07,00 FEC <br /> rRCQVIzSST PROCESSGO IN ) DUSINCSS DAYS elk <br /> I <br /> SIGNATURE OF APPLICANT /inn. V �/f�`r DATE fit I 4(�4 <br /> FILE ADDRESS THIS SIDE CND STAFF USE ONLY <br /> PROGRAM ELEMENTS SEARCH ' <br /> tat.�S a Lk lc Ave El <br /> � � � . �fdlt ,nnl ►i NLU�A ca .2_ �7 5D � /? %7Cr�7 i( ) {/ <br /> If <br /> t_ <br /> 44q A%I <br /> /I le Aa F16kikeeill A ViIieffee%I CLN o f .-- - <br /> ENVIRONMENTAL HEALTH DIVISION FILES <br /> UNDERGROUND TANK (UST) CLEANUP SITE (LOP) ❑ HOUSING ABATEMENT ❑ SOLID WI FACILITY <br /> ❑ OTHER CLEANUP SITE (NON-LOP) ❑ FOOD FACILITY ❑ SOLID WASTE VEHICLE <br /> ❑ UNDERGROUND TANK (MONITORING/REMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR O CHICKEN RANCH ❑ PKG TREATMENT PLANT <br /> 4 TIERED PERMIT74D FACILITY ❑ MOTFUNOTEL ❑ PUMPERTRUCKfYARDICHCM TOILETS <br /> ❑ TATTOOIBODY PHIRCING ❑ POOLISPA " � ❑ LAND USE APPLICATION SITES <br /> ❑ MEDICAL WASTE; FACILITY ❑ PUBLIC WATER SYSTEM ❑ OTHER (PLEASE SPECIFY AOOVE) <br /> 1 . List up to ten addresses in the space above. Select the type(s) of files from the list above by checking <br /> theappropriate box(es) . At ( oast one file type MUST be selected, Fax to (209) 464-0138 or mail to the <br /> address indicated above <br /> Z FHD 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 now <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 $ t17,o0 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 PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> iH lig +�arrow <br />