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Uri'i RLCLIVED LHIU LUu N(jM0L'k <br /> SAN JOAQUIN COUNTY � f <br /> E R4NMENTALL HEALTH DEPAR ►TENT <br /> 304 E Weber Ave 3rd Floor Stockton, CA 95205 <br /> (209) 468-3420 Fax: (209) 464-0138 Web: www.co-san-joactuin.Ca.us/chd <br /> PUBLIC RECORDS RELEASE APPLICATION <br /> APPLICANT: i ^�I 1 V� BUSINES GENCY:i~ I �I i l �C �.C1 <br /> ADDRESS: <br /> PHONE:. `�C. <br /> FACSIMILE: <br /> TENTATIVE"APPOINTMEI T DATE: Time: <br /> V <br /> (Piease:ali w 10 business days from date at application submittal) <br /> CHECK BOX TO EXPEDITE REQUES -$93 UD FEE-REQUEST PROCESSED..IN 3 BUSINESSDAYS <br /> C) <br /> SIGNATURE OF-APPLICANT <br /> Department Use Only <br /> F E ADDRESS 4 UNIT <br /> GI / <br /> ?. Sircct .�r ..:.y , .C1•I,.,_. . ,... .. _ .,. ... w y... .❑ Unit 1 . <br /> 2 Street Cil <br /> .. Streel Co ❑ ... Unit 2 <br /> 5. S[rcct Cd ' <br /> 6. Streel - ❑ Unit 3 <br /> Ct <br /> 7. Streel GI 1' <br /> 6. Street ., - . .-. Unit 4 <br /> 9, strec[ - <br /> �u ❑ . <br /> 10. Slrret Unit 5cd <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> ❑ UNDERGROUND TANK(UST)CLEANUP SITE(LOP) ❑ HOUSING ABA7E:MENT 'Cl'-SOLID WASTE FACILITY• <br /> ❑ OTHER CLEANUP SITE{NON-LOP} " D FOOD FACILITY' ❑ SOLID WASTE VEHICLE ' <br /> ❑ UNDERGROUND TANK(MONITORINGIREMOVAL) ❑ DOG KENNEL ❑ DAIRY <br /> ❑ HAZARDOUS WASTE GENERATOR 0 CHICKEN RANCH ❑ PKG TREATMENT PLANT ' <br /> ❑ TIERED PERMITTED FACILITY ❑ MOTEL/HOTEL ❑ PUMPER TRUCK/YARD/CHEM TOILETS <br /> ❑ TATTOOIBODY PIERCING ❑ POOLISPA ❑ LAND USE APPLJCATION SITES <br /> ❑ MEDICAL WASTE FACILITY HER{PLEASE 5PECIF 5 <br /> 1 Y)liG( L_C 0 Vit!n^Q� �U/1-�/YfG�ilt/I r�1y. <br /> (57 ,;2e-c1y <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. EHD will notify the applicant if any EHD tiles 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 EH0 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 rel iews 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 PHONE FAX INITIALS <br /> REVIEWED YES NO REVIEW DATE <br /> END 46-0z•a0fi <br /> Mrt. G• �'t�v.�l �;rn oN/�t �o�t1 �' G.r Sun►�z��u <br /> 0 . <br />