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i <br /> ���� D ��/} EHD LOG NUMBER <br /> 1�I�0 SAN JOAQUIN COUNTY <br /> I� ENVIRONMENTAL HEALTH DEPARTMENT <br /> ��� 2 7 � 304 E Weber Ave 3"1 Floor Stockton,CA 95205 <br /> } 468-3420 Fax., (20 9)464-0138 Web: www.co.san-joaquin.ca.us/chd <br /> ENVIRONMENT HEALTH q6 - S' R <br /> PERN!iT S E RVI C F S PUBLIC RECORDS RELEASE "PLICATION <br /> APPLICANT: '"" BUSINESSIAGENCY: <br /> ADDRESS: l� f N.6 r ire ?_!00 <br /> PHONE: �c%� r'3 __ FACSIMILE: <br /> TENTATNE`APPOiNTmENT DATE: <br /> {Please allow 10 business drys From date o appli tion su mittal) <br /> _jWCHECK BOX TO EXPEDITE REQUEST 93.00 F=E—.REQUE T PROCES$Eb IN 3 BUSINESS DAYS <br /> L7AE 7Z1D 1 <br /> SIGNATURE OF APPLICAIIT ' <br /> DeP3rtmer%t Use Only <br /> FILE ADDRESS UNiI n <br /> Unit i <br /> Z _ <br /> a. surto ;Bill W- _ l-�.h !sfKtf' . - Cny - � 0 Unit 2 <br /> ssmot _ C <br /> &f*S. 5(m.aI ,,, Clry <br /> 7. „Svaa1 ._ �•. - S <br /> 70. If.:iPf cllY - - <br /> ENVIRONMENTAL HEALTH DEPARTMENT FILES <br /> UNDERGROUNO TANK(UST)CLEANUP SITE,(LOP) ❑ HOUSING ABATr:MENT [3 SOLID WASTE FACILITY <br /> �L OTHER CLEANUP SITE INON-LOPI ❑ FOOD FACILITY Cl SOLID WASTE VEHICLE <br /> W UNDERGROUND TANK(MONITORINGIREMOVAL) 0 DOG KENNEL ❑ DAIRY <br /> to HAZARDOUS WASTE GENERATOR •0 CHICKEN RANCH 0 PKG TREATMENT PLANT <br /> ❑ TIERED PE:RMIITfEO FACILITY 0 MOTELIHOTEL 0 PUMPER TRUCKIYARDICHEM TOILETS <br /> ❑ TATTO018013Y PIERCING 43 POOUSPA ❑ LAND USE APPLICATION SITES <br /> 0 MEDICAL WASTE FACILITY ❑ OTHER(PLEASE SPECIFY) <br /> f. List up to ten addresses in the space above. Select the type($)of files from the list above by checking <br /> the appropriate box(es). At least ane 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 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 i5 actively being worked on by EHD staff may not be immediately available for review. Anew <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 /> S. =TENTATIVE appointment dates must be confirmed with EHD staff. <br /> 6. Applications received after 3,_Oo pin 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 /> EHD 4&cz.o06 — 1 <br /> am�mm <br /> k <br /> 4 <br />